Duross-Cohen, Lamia NEW YORK STATE DEPARTMENT OF HEALTH N` f
Vital Records Section Burial - Transit v ermit
Name First Middle Last Sex
Lamia Duross-Cohen Female
Date of Death Age If Veteran of U.S.Armed Forces, I
February 3, 2014 ,.'�fZ.}' War or Dates
Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death 0 Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
`a
Anne Soucy, M.D. Dr.
Address
101 Ridge Street Glens Falls, NY 12801
h Certificate File/d_. District Number Register Numbei
C ty own or Village( -i,e s I-4,1 Is 5601
❑Burial Date Cemetery or Crematory
February 6, 2014 Pine Vew Crematorium
❑Entombment Address
®Cremation Queensbury,NY 12804
Date Place Removed
7 ❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
P= by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
,I: ❑ Reinterment Date Cemetery Address
¢. Permit Issued to Registration Number
itk Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
'.i Name of Funeral Firm Making Disposition or to Whom
}—,; Remains are Shipped, If Other than Above
Address
Lu
Permission is her by granted to dispose of the human remains described above as indicated.
:., Date Issued 2-/6/ Q/'`/ Registrar of Vital Statistics W ot,jri,.Q_
(signatu )
District Number D(001 Place Cz)-PnS l i tS i N\J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ur Date of Disposition 02/06/2014 Place of Disposition Queensbury,NY 12804
(address)
W:
3 (section) /lo t number) (grave number)
Name of Sexton or Person in Charge of Premises /_ ti..ifi �n►vii
(ple9sr e print)
Signature Title Cirovrrrid
(over)
DOH-1555 (02/2004)