LaFountain, TerryLee \ ,?7
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Terrylee LaFountain Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/18/2020 61 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Saratoga Springs Street Address Saratoga Hospital
• Manner of Death
Natural Cause El Accident ElHomicide I=1 Suicide 0 Undetermined 0 Pendign
W U Circumstances Investigation
W Medical Certifier Name Title
O Enrico Bravo MD
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Saratoga Springs 4501 671
ElBurial Date Cemetery,Crematory or Facility Name
12/22/2020 Pineview Crematory
ElEntombment Address
]Cremation Queensbury Town,New York
Donation
Removal Date Place Removed
and/or and/or Held
A Hold Address
0
a Date Point of
to Li Transportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
Cr
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/22/2020 Registrar of Vital Statistics John Paul Franck(Electronically Signed)
(signature)
District Number 4501 Place Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-
Z Date of Disposition /2-13 2O Place of Disposition p, re.,) C,' 1.-ot%4"11/
(address)
W
N Cr (section)) (lot number) (grave number)
j• Name of Sexton or Pers• in Charge of Premises G� i7� ✓1 V�vn �-c�1►e
O (please print)
j M
W Signature /�. Title e f m a�-U / D7c
DOH-1555(07/18)p 1�
Public Health Law Sec. 4145(2b) - 01 3 2 i
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#