LaRock, Daniel NEW YORK STATE DEPARTMENT OF HEALTI4 `1(21)
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
DANIEL LYNN LAROCK 'E
Date of Death A e If Veteran of U.S. Armed Forces,
OCTBOER 17, 2006 58 War or Dates NO
i4 Place of Death Hospital, Institution or
.L City, Town or Village LITTLE FALLS Street Address VAN ALLEN NURSING HOME
0 Manner of Death®Natural Cause 0 Accident Homicide Suicide Undetermined Pending
ILICircumstances Investigation
iti Medical Certifier Name Title
RUSSELL ZE AN M.D.
Address755 E. MONROE ST., Cf.TTLE FAILS, NY 13365
Death Certificate Filed District Number Register Number
City, Town or Village LITTLE FALLS 2129
['Burial Date Cemetery or Crematory
OCTOBER 20, 2006 PINE VIEW CREMATORY
j ❑Entombment Address
» ®Cremation TOWN OF QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
0❑and/or Address
E Hold
U)
Date Point of
fki Q Transportation Shipment
C! by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to M. B. KILMER FUNERAL HOME Registration Number
Name of Funeral Home 01141
Address
136 MAIN ST., SOUTH GLENS FALLS, NY 12803
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
ili
fu
'▪` Permission is hereby granted to dispose of the human rema' described bove as indicated.
Date Issued Registrar of Vital Statistics
(signature
District Number Q 1 aci Place Ll J_ ",Aii.e.
I certify that the remains of the decedent identifi d above were disposed of in accordance with this permit on:
Date of Disposition i 0 /-10/6(. Place of Disposition f,Pu.,if.✓ Ct,rr&s ;,f-t o,h
(address)
In
?lam
i? (section) r(lot number) (grave number)
CI Name of Sexton o /�Person in harge of Premises is 1 r"s 3tm Yu
2 (please print)
W. Signature Title C cirlf
(over)
DOH-1555 (02/2004)