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Wiegert, Lois if VI S NEW YORK STATE DEPARTMENT OF HEALTH Burial Records Section Burial - Transit Permit y Name First Middle Last Sex Lois Ann Wiegert Female Date of Death Age If Veteran of U.S. Armed Forces, December 29, 2012 80 War or Dates k Place of Death Hospital, Institution or Zs City, Town or Village Glens Falls,NY Street Address Glens Falls Hospital 00 Manner of Death X Natural Cause n Accident L Homicide n Suicide Undetermined Pending A1,1 Circumstances - Investigation u. ut Medical Certifier Name Title CI Mark Hoffman,MD Address Glens Falls,NY Death Certificate Filed District Number Register Number City, Town or Village Glens Falls,NY 5601 0I ❑Burial Date Cemetery or Crematory December 31,2012 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road, Queensbury,NY 12804 Date Place Removed ZO n Removal and/or Held and/or Address H Hold N O Date Point of g5n Transportation i Shipment p` by Common Destination Carrier n Disinterment Date Cemetery Address n 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 I— Remains are Shipped, If Other than Above X Address r LIJ 4:' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12../ 3 1 it 2 Registrar of Vital Statistics ./\)C -A- ,.s2. \ AJAJ-9-14— (signature) District Number 5601 Place Glens Falls,NY Pio I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 1-5-0 Place of Disposition -F.et)40 Ce,��pr,u.� 2 (address) co 0 (section) lot number) (grave number) Z Name of Sexton or Person in Charge of Premises /L, j — ,,'1t-r�- (please print) to 41Signature Title CR;F,F1t}iail., (over) DOH-1555(02/2004)