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Lefebvre, Bonita NEW YORK STATE DEPARTMENT OF HEALTH It 5gq Vital Records Section Burial - Transit Permit Name First Middle Last Sex Bonita A. Lefebvre Female Date of Death Age If Veteran of U.S. Armed Forces, September 30, 2013 67 War or Dates 'la - of Death Hospital, Institution or w City, Town or Village Glens Falls Street Address Glens Falls Hospital W k I- ner of Death EI Natural Cause El Accident ❑ Homicide 0 Suicide Undetermined Pending Circumstances Investigation WWt.,3 Medical Certifier Name Title Michael Fuller, M.D Address 48 East Street Fort Edward, NY 12828 n P Certificate Filed/ . District Number 6 Register Number Town or Village C�/.e n S I—cc.-l ( S �� Li ( H ■ :urial Date Cemetery or Crematory October 3, 2013 Pine View Crematorium w.L. Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed • 0 Removal and/or Held 0 and/or Address p Hold Pine View Crematorium O n Date Point of • I I Transportation Shipment 0) by Common Destination 0 Carrier ElDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number 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 Name of Funeral Firm Making Disposition or to Whom I Remains are Shipped, If Other than Above • Address :CC, WZa.:. ,, Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued I o j 3//_? Registrar of Vital Statistics C.M.NQ (signs .re) District Number 56 p i Place 6 S \,1 S y q :_ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 10 I3'l, Place of Disposition 7,J ! Co•-wite 0�- 2 (address) `W co te (section) /tSk ot number) (grave number) O �' ft- Ca Name of Sexton or Person in arge of Pr mises SHw Z; (pl ase print) LU Signature Title C4 t`14yrn_ (over) DOH-1555 (02/2004)