LeClair, Louise /v
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ` r Burial - Transit Permit
* Name First Middle Last Sex
. Louise Mae Le Clair Female
f 3, Date of Death Age If Veteran of U.S. Armed Forces,
01/17/2018 91 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 Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Marcille Labban MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 32
Y ,;ri Date Cemeteryor Crematory
ter, Burial
• ,f 01/19/2018 Pine View Crematory
0 Entombment
x Address
Irio
Via':
®Cremation Queensbury Town, New York
Date Place Removed
�• Removal and/or Held
and/or Address
Hold
Date Point of
I Transportation Shipment
by Common Destination
Carrier
• Disinterment
Date Cemetery Address
` � Date Cemetery Address
,,• Q Reinterment
54 Permit Issued to Registration Number
i
Name of Funeral Home Maynard D Baker Funeral Home 01130 x
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 01/19/2018 Registrarof Vital Statistics� Robert Curtis(ECectronicaCCy Signed)
z' (signature)
District NumberPlace}' 5601Glens Falls, New York
°'.; I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition //L3 j1g Place of Disposition f7„ 1✓ e. Ta i�-
(address)
(section) (lot number) (� (grave number)
Name of Sexton or Person in Charge of Premises L ^,.m�✓ J L-,tfr`l`
(p se print)
14 Signature "1 G Title AI EMMY-
(over)
DOH-1555 (02/2004)