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Larson, Oda ril NEW YORK STATE DEPARTMENT OF kEA Burial - Transit Permit Vital Records Section Name First dle 7 Last Sex Oda Larson ., Female Date of Death Age If Veteran of U.S.Armed Forces, 09/09/2018 98 Years War or Dates 1- Place of Death Hospital, Institution or WCity, Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation p Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El❑Pending Circumstances Investigation W Medical Certifier Name Title O Gwendolyn Morris-Dickinson PA Address 170 Warren St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 429 ❑Burial Date Cemetery or Crematory 09/10/2018 Pine View Crematory ['Entombment Address ®Cremation Queensbury, New York Date Place Removed Z❑Removal and/or Held O and/or Address H Hold U, O Date Point of 0❑Transportation Shipment G by Common Destination Carrier ❑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 Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped, If Other than Above 2 Address E tit L Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/10/2018 Registrar of Vital Statistics W96ertA Curtis(E(ectronica((ySigned) (signature) 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: W Date of Disposition '1IZIIg Place of Disposition fPniv../ fr,, e.,—. 2 (address) W CO CZ (section) (lot number) ( (grave number) pName of Sexton or Person in Charge of Premises thnitoptr J e4i4 Z (p/e a print) W di 4 Signature - Title *Mid (over) DOH-1555 (02/2004)