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Conforth, Loretta Li° 1 NEW YORK STATE p5PARTMENT OF HEALTH Vital Records Section Burial - Transit Permit aF; Name First Middle Last Sex Loretta Conforth Female Date of Death Age If Veteran of U.S. Armed Forces, December 19,2015 87 War or Dates .. Place of Death Hospital, Institution or City, Town or Village Queensbury Street Address Westmount Health Care Facility —: Manner of DeathUndetermined Pending `�= X Natural Cause I I Accident Homicide Suicide Akt Circumstances Investigation lam, Medical Certifier Name Title , j Roslyn Socolof Address • 14 Manor Drive,Queensbury,NY 12804 • Death Certificate File District Number Rygister Number Cit6 y owno� Villagei�Q���� 5657 (,(,) ❑Burial Date Cemetery or Crematory December 21,2015 Pine View Crematory ❑Entombment Address ©Cremation 21 Quaker Rd., Queensbury, NY 12804 Date Place Removed Z Removal and/or Held O and/or Address H Hold co O Date Point of N I 1 Transportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address y• Permit Issued to Registration Number Name of Funeral Home Alexander-Baker Funeral Home 00037 Address 3809 Main Street,Warrensburg,NY 12885 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2; Address At t11 • "° Permission is hereby granted to dispose of the human re ains described above as indicated. Date Issued b.]�-�-1 I Registrar of Vital Statistics - Cl,`--' N3 ri,L (signature) — District Number 5657 Place c)u-- v c--(, (gip 0.4-vCio H I certify that the remains of the decedent identified above were disposed of in acco • :- with this permit on: Z W Date of Disposition 12 23=/c Place of Disposition ? :7-)e . ►e..,,) re.mw�e�y 2 (address) W co w (section) (lot number) (grave number) pName of Sexton or Person in Charge of Premises , /t...4 C.1ti...na.tih� Z (please print) W Signature Title er -snc..�a."' (over) DOH-1555 (02/2004)