Lapham, Jean %S L
NEW YORK STATE DEPARTMENT OF HEALTH` *Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jean Hurme Lapham Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 17, 2013 80 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death n Natural Cause n Accident 0 Homicide n Suicide n Undetermined Pending
) Circumstances Investigation
w Medical Certifier Name Title
CI
Address
Death Certificate Filed Glens Falls District Number Register Number
City, Town or Village 5601 //
❑Burial Date Cemetery or Crematory
March 19, 2013 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
O n Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
NI I Transportation Shipment
p by Common Destination
Carrier
n 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
1 Remains are Shipped, If Other than Above
a Address
re
IL, Permission is her by It3ed to dispose of the human r(mains de ribed ab e as Indic ted. r
Date Issued �ORegistrar of Vital Statistics s Gi- —sn 2 _._
(sig ature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were di osed of in accordance with this permit on:
Z p 3 dl- 13 Place of Disposition P yj. VI ,,u �Gw.c\ k 1f
� Date of Disosition
(address)
W
co
Q: (section) (lot number) \\ (grave number)
QName of Sexto or P rso . harge of Premises Sid Aouz 1 ✓'MG
" (please(p print)
Ill SignatureGL Title �ret'r"4- 1 -1.
(over)
DOH-1555(02/2004)