Decesare, Lorraine * ' k i 1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lorraine H Decesare Female
Date of Death Age ' If Veteran of U.S. Armed Forces,
12/13/2013 85 years War or Dates
1-; Place of Death Hospital, Institution or
Z City, Tow9j(ilt, XX Glens Falls Street Address Glens Falls Hospital
• Manner of Death{Natural Cause D Accident El Homicide El Suicide ri Undetermined El Pending
MI Circumstances Investigation
W Medical Certifier Name Title
41. farci A Gaintti-gnihhs M n
Address
102 Park St Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, Towi>QJ it SXXX Glens Falls 5601 537
❑Burial Date Cemetery or Crematory
❑Entombment 12/16/2013 Pineview Crematory
Address
[JCEyemation Queensbury, N Y 12804
Date Place Removed
Removal and/or Held
.... and/or Address
t Hold
O Date Point of
05 ❑Transportation Shipment
d by Common Destination
Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Edward L. Kelly Funeral Home 00519
Address
Schroon Lake, N Y 12870
Name of Funeral Firm Making Disposition or to Whom
1, Remains are Shipped, If Other than Above
• Address
L
` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/13/2013 Registrar of Vital Statistics (./,-)
(signatur
District Number Place `J L)
5601 Glens Falls/ /V r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lt! Date of Disposition la-Ii-i3 Place of Disposition Reaty ..40i,,.—
(address)
at
CO
CC (section) /i (lot number (grave number)
ct Name of Sexton or Person i harge of remises Ate ri/4a
"NtF
(please print)
W.
Signature Title 011Vdd
(over)
DOH-1555 (02/2004)