Ladabouch, Rita M. It?
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
t ' Name First Middle Last Sex
f, Rita M.Ladabouch Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/23/2021 80 Years War or Dates
lH Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
Ili
p Manner of Death 0 Natural Cause 0 Accident ❑Homicide E Suicide ❑Undetermined El Pending
W U Circumstances Investigation
UJ Medical Certifier Name Title
O Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate File , le District Number Register Number
City,Town or Village, " ' Queensbury 5657 30
▪Burial ate Cemetery,Crematory or Facility Name
r:, /2021 Pine View Crematory
0 Entombment Address
0 Cremation Queensbury Town,New York
O Donation
Z n Removal Date Place Removed
and/or and/or Held
H Hold Address
M
0
U. Date Point of
Cl) ❑Transportation Shipment
Q by Common
Carrier Destination
Date Cemetery Address
❑Disinterment
Date Cemetery Address
ElReinterment
Permit Issued to Registration Number
Name of Funeral Home Regan&Denny Funeral Service 01444
Address
94 Saratoga Ave,S Glens Falls,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F— Remains are Shipped,If Other than Above
2 Address
CIC
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/26/2021 Registrar of Vital Statistics Carolinexf.fegard Barber(EYectronrca(Signer!/
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit�n: / 4.----
Z Date of Disposition 2(u1'Z' Place of Disposition
rL osition r.
LLI
2 (address)
W
(r (section) (lot num (grave number)
S Name of Sexton or Person in Charge f Premises fil P` -
AMatf
Z (please print)
W Signature G� Title G'"�r�rt��E
g
DOH-1555(07/18)p i of 2
Public Health Law Sec. 4145(2b) in, =�
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named On burial permit
Official Funeral Directors Reg.or License#
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