Ottens, Lorraine NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section -Burial - Transit-Permit
Name First Middle Last Sex
Lorraine Mary Agnes OTTENS F
Date of Death Age If Veteran of U.S. Armed Forces,
Jan 2 2, 1 9 9 9 6 5 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital
;. Manner of Death 0 Natural Cause ❑Accident ❑Homicide Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Amy Hogan-Moulton Title MD
Addressg0 South St Suite A Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs 4501
DateJan 26 1999
El Burial Cemetery or Crematory
Pineview C
Quaker Rd Queensbur
Cremation Address Q y
Date Place Removed
z❑Removal and/or Held
and/or Address
Hold
0 Date Point of
❑Transportation Shipment
by Common Destination
Carrier
.. ❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to RecListr ton Number
Name of Funeral Home Simone Funeral Home INC U1 '�64
`< Address
105 Lake ave Saratoga Springs, NY 12866
>s 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 re ma" s sc dab ndic ted.
Date Issued 1 /2 5/9 9 Registrar of Vital Statistics
(sign re)
District Number 4501 Place Public Safety Saratoga Springs, NY
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Place of Disposition
(address)
(section) (lot number). (grave number)
GName of Sexton or Person in Charge of Pre ises G r.,` �� Cz-ia.1�
z (please print) _
Signature Title P+/) �Z_�
(over)
DOH-1555 (9/98)