Gagne, Lena NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Lena Gagne Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/09/2021 81 Years War or Dates
E.,, Place of Death Hospital,Institution or
WCity,Town or Village Albany Street Address Albany Medical Center Hospital
0 Manner of Death 0 Natural Cause 0 Accident 0 Homicide El Suicide 0 Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
G Francine Damato PA
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed District Number Register Number
City,Town or Village Albany 0101 0731
ElBurial Date Cemetery,Crematory or Facility Name
03/12/2021 Pine View Crematory
0 Entombment Address
iCremation Queensbury Town,New York
El Donation
Z Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0 Date Point of
(I) Li Transportation Shipment
Q by Common
Carrier Destination
Date Cemetery Address
0 Disinterment
Date Cemetery Address
ElReinterment
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
p— Remains are Shipped,If Other than Above
2 Address
Q
W
CI. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/12/2021 Registrar of Vital Statistics Dania.Sctllerpre(E/ctronicall:y Stgned)
(signature)
District Number 0101 Place Albany, New York
I certify that the remains of the decedent identified above were disposed of?,'
in accordance with this permit on:
I—
WDate of Disposition j/j-�p;,2/ Place of Disposition rv'e t/ a°� (addr �J2
W
CO
CC (section) rr// (lot nu�mbbe (grave number)
SName of Sexton or Person in Ch rge of Prem' �70`' w�'"�
(please print)
Z ` ! �
Ill /Signature 7fi4 / 1 Title (974
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) .1 4 09
1
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# 1