Anderson, Marie A C
NEW YORK STATE DEPARTMENT OF HEALTH �yzo
Buria� - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Marie A Anderson Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/20/2022 80 Years War or Dates
f- Place of Death Hospital,Institution or
W City,Town or Village Lake Luzeme Town Street Address 1942 Call Street,Lake Luzerne Town, New York 12846
0 Manner of Death n Natural Cause Accident ri Homicide OSuicide (Undetermined El Pending
W U f 'Circumstances Investigation
W Medical Certifier Name Title
O Melanie Duerr NP
Address
47 Tom Phelps Lane,Mineville Hamlet,New York 12996
Death Certificate Filed Town Of Lake Luzeme District Number Register Number
City,Town or Village 5656 11
Burial H
Date Cemetery,Crematory or Facility Name
05/24/2022 Pineview Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
tL Date Point of
Cl)❑Transportation Shipment
p by Common
Carrier Destination
o
Disinterment
Date Cemetery Address
Date Cemetery Address
❑Reinterment
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
1— Remains are Shipped,If Other than Above
2 Address
Q
W
f1 Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/23/2022 Registrar of Vital Statistics Cynthia Sherwood(Electronically Signed)
(signature)
District Number 5656 Place Town Of Lake Luzeme
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ZW Date of Disposition gi211 02_ Place of Disposition
2 / res
W
Cocc (section) /if (lot number)
Name of Sexton8 or Person in Ch a of Premises
(grave number)
l ►1 fi' __ ( hvf tt
z (please print)
W Signature Title ire"14-7 0r
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of ' delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#