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LaPoint, Shirley NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section 4 Burial - Transit Permit Name First Middle Last Sex Shirley Ruth LaPoint Female Date of Death Age If Veteran of U.S. Armed Forces, June 28, 2014 76 War or Dates NO 1 - Place of Death Tn of Moreau Hospital, Institution or 393 Gansevoort Rd. WCity, Town or Village Street Address. W Manner of Death©Natural Cause ❑Accident El Homicide El Suicide ri❑Undetermined ❑Pending Circumstances Investigation id Medical Certifier Name Title CE Mark Hoffman MD Address 102 Park St. Glens Falls, New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Tn. of Moreau LI5(o Z 13 ❑Burial Date Cemetery or Crematory July 7, 2014 Pine View Creamtory El Entombment Address ❑Cremation 21 Quaker Road Queensbury, New York 12804 Date Place Removed Z❑I—IRemoval and/or Held and/or Address i= Hold U) 0 Date Point of fki ❑Transportation Shipment G by Common Destination Carrier Q Disinterment Date Cemetery Address . Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeal Home 01 078 Address 136 Main St. South Glens Falls, New York 12801 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above s Address tr to Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 9-1 - (t( Registrar of Vital Statistics jffiritil M. A Q_Ithiy (signature) District Number U5(02 Placec_35) 2r,Illj s RDAb da/26AA /\JL/ /7,2 �' 5 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: LEI Date of Disposition 1-1S-1'4 Place of Disposition golk4J 64^40 fit", (address) III ii C (section) of number) (grave number) G Name of Sexton or Person in Charge of Premises 'f �o' alt 2l (pie e print) Signature dr* A, —•' Title C ZM.M1 (over) DOH-1555 (02/2004)