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LaRose, Irene I NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section / Burial - Transit Permit t Name First Middle Last Sex _ Irene M.LaRose Female Date of Death Age If Veteran of U.S.Armed Forces, 04/26/2018 95 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Granville Town Street Address The Orchard Nursing And Rehabilitation Centre Tr Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation t ; Medical Certifier Name Title — ` Jennifer Hayes MD Address 10421 State Route 40,Granville Town,New York 12832 Death Certificate Filed District Number Register Number City, Town or Village Granville 5756 13 ❑Burial Date Cemetery or Crematory 05/01/2018 Pine View Crematory ❑Entombment Address ®Cremation Queensbury Town, New York Date Place Removed rr❑Removal ‘ and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Renterment Date Cemetery Address le_ Permit Issued to Registration Number Name of Funeral Home Jillson Funeral Home Inc 00885 µj Address .4 46 Williams Street,Whitehall Village,New York 12887 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 04/30/2018 Registrar of Vital Statistics Jenny Linda Wartelle(ECectronicaltySigned) (signature) District Number 5756 Place Granville, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 4 Date of Disposition SV3 IN Place of Disposition eM .,� ,+r0p., (address) 114 (section) /l(lot number) (grave number) Name of Sexton or Person in Charge of Premises `"`, S /1� (p se prin -_ Signature e 4 Title temript (over) DOH-1555 (02/2004)