Lapham, Gloria _*c„, tk
ii 1 Z4
NEW YORK STATE DEPARTMENT OF HEALTH ��
Vital Records Section Burial - Transit Permit
15 Name First Middle Last Sex
qg Gloria C. Lapham Female
:<> Date of Death Age If Veteran of U.S. Armed Forces,
f July 25,2013 89 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 64 Chestnut Ridge Road
Manner of Death12_ Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
'I,. Dr Gara,MD
f,r:,�
'' Address
'' Fort Edward,NY
,
Death Certificate Filed District Number Register Number
f City, Town or Village Queensbury,NY 5657
❑Burial Date Cemetery or Crematory
El Entombment July 29, 2013 Pine View Crematorium
Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ ri Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
%r' Permit Issued to Registration Number
44 Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury,NY 12804
,� Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human r ains described a ye as indicated.
Date Issued 1 - )..(` -.)-(Ai Registrar of Vital Statistics '.4Ak ��
(signature)
iN i District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 1-31-113 Place of Disposition -t''../LOcw Cam,-4&..se-_.
Ili
(address)
N
W (section) (lot number) (' (grave number)
pName of Sexton or Person in Charge of Premises ;•,} r !��► 1
Z (plea e print)
W Signature 4, -L---
Title e fL
(over)
DOH-1555(02/2004)