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LaRose, Violet Rose NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle 1 Last Sex Violet Mae LaRose Female Date of Death Age If Veteran of U.S.Armed Forces, 11/20/2021 94 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc pManner of Death ©Natural Cause ID Accident ❑Homicide ❑Suicide ❑Undetermined El Pending W Circumstances Investigation W Medical Certifier Name Title C3 Came Miron PA Address 319 Broadway,Fort Edward Town,New York 12828 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 67 ©Burial Date Cemetery,Crematory or Facility Name 11/29/2021 Pine View Cemetery EiEntombment Address ❑Cremation Queensbury Town,New York ❑Donation Z ❑Removal Date Place Removed and/or and/or Held i= Hold Address N 0 O. Date Point of - U) ❑Transportation Shipment p by Common Carrier Destination Disinterment Date Cemetery Address ElReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom 1.. Remains are Shipped,If Other than Above a Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/22/2021 Registrar of Vital Statistics Aimee L Mahoney(E(ectronically Signed) (signature) District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: IF- Z Date of Disposition 11 -29.21 Place of Disposition 21 Quaker Rd. Queensbury, NY 12804 W (address) W Seneca 24A 1 Cl)CC ection) (lot number) (grave number) 8 Name of Sexton or Person in Charge of Premises Connie Goedert Z (please print) W Signature nit-4-2 e— Title Superintendent • DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) U 12883 Receipt • Human remains of '4 : delivered on , 20• Pine View Cemetery Representing the funeral home named on.burial permit Official Funeral Directors Reg.or License# i4'r i LAROSE NAME Violet LaRose Age: 94 Lot Owner: Violet LaRose Lot# Seneca 24 A Grave# 1 Case: Concrete Died: 1 1 .2 0.21 Interred:1 1 .29 .21 Funeral Home: Carleton FH Cemetery: Pine View