LaCroix, Deborah NEW YORK STATE DEPARTMENT OF HEALTH' '
Vital Records Section Burial - Transit Piii IT ermit
Name First Middle Last Sex
Deborah Lee LaCroix Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 10, 2014 55 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Grandville Street Address 228 Beecher Road
Iii
Manner of Death ' Natural Cause E Accident n Homicide E Suicide n Undetermined n Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Kevin A. Gallagher Dr.
Address
79 North St,Granville,NY 12832
, Death Certificate Filed District Number Register Number
City, Town or Village Town of Granville 5756 a a
El Burial Date Cemetery or Crematory
D Entombment May 14,2014 Pine View Crematorium
Address
0 Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z n Removal and/or Held
2 and/or Address
H Hold __
Cl)
0 Date Point of
N n Transportation Shipment
p by Common Destination
Carrier
Li Disinterment Date _ _ _ Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
U#;
4 Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued OS 1 i 4 l of V Registrar of Vital Statistics oS wt.4 ("ilea_
(si nature)
District Number 5756 Place Town of Granville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition §-tri'( Place of Disposition -[Li 04Y.,uti
LU (address)
(I)
0 (section) dirk
- (iot nupber) (grave number)
p Name of Sexton or Person in Charge of Premises se.4t
Z (please print)
W Signature ��" Title �-t7d
T.
(over)
DOH-1555(02/2004)