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LaMore, Agnes NEW YORK STATE DEPARTMENT OF HEALTH 4d Vital Records Section `I* Burial - Transit Permit Name First Middle Last Sex Agnes R. LaMore Female Date of Death Age If Veteran of U.S.Armed Forces, NO I. June 23, 2014 87 War or Dates 2 Place of Death Hospital, Institution or W City,Town,or Village Glens Falls Street Address Glens Falls Hospital a Manner of Death X❑ Natural Cause El Accident ❑Homicide ❑Suicide 0 Undetermined ❑ Pending W Circumstances Investigation U Medical Certifier Name Title W Dr. Dean Reali, M.D. Dr. 0 Address 3767 Main Street, Warrensburg, NY 12885 Death Certificate Filed District Number Register Nu ber City,Town or Village Glens Falls 56 i/ �9'' ❑Burial Date June 27, 2014 Cemetery or Crematory/ Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury New York Z Date Place Removed 0 ❑ Removal and/or Held - and/or Address I" Hold 0 Date Point of 0 El Transportation Shipment A by Common Destination i Carrier Date Cemetery Address ii0 Disinterment Reinterment , Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Jillson Funeral Home, Inc. 00885 Address 46 Williams Street, Whitehall, New York 12887 ~ Name of Funeral Firm Making Disposition or to Whom M Remains are Shipped, If Other than Above CC W Address O. Permission is hereby ranted to dispose of the human remains descri d)a ove ssited. �Date Issued OG 0z 'Y Registrar of Vital Statistics 4 d (signature) District Number • �40/ Place Glens Falls,New York F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition to I3o I ly Place of Disposition Our Lady of Angels Cemetery 2 (address) W v` td 0 (section) of number) (grave number) ZName of Sexton or Person in Charge of Premises In sit411.1 r .CLih ' (plea a print) Signature 4,- Title 6-174 rAA'(flld (over) DOH-1555 (02/2004)