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Leroux, Donna NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Donna Hazel Leroux Female rge Date of Death Age If Veteran of U.S. Armed Forces, Ztli 04/02/2018 64 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death©Natural Cause 0 Accident El Homicide El Suicide El Undetermined El Pending Circumstances Investigation Medical Certifier Name Title Sean Bain MD 11 Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 164 ,p ❑Burial Date Cemetery or Crematory 04/02/2018 Pine View Crematory ❑Entombment Address ®Cremation Queensbury Town, New York Date Place Removed g-❑Removal and/or Held and/or Address Hold Date Point of Q Transportation Shipment ,,`_ by Common Destination Carrier kt,Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address krzPermit Issued to Registration Number Name of Funeral Home Maynard D Baker Funeral Home 01130 ,!-41 Address 11 Lafayette St,Queensbury,New York 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 remains described above as indicated. Date Issued 04/02/2018 Registrar of Vital Statistics Rp6ertA Curtis(fE(ectronwcal y Signed) (signature) iff District Number 5601 Place Glens Falls, New York � I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: , i Date of Disposition ii/yll$ Place of Disposition �N\I--- lr= 4ofI--- (address) (section) (lot number) (grave number) f Name of Sexton or Person in Charge of Premises rI ,�,.�P1' ( se print) le Signature U Title (Oft (over) DOH-1555 (02/2004)