LaPointe, David NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
ii Name First Middle Last ' Sex
cl R+� orr L try.�n-.L H
V
€I Date of Death Age If Veteran of U.S. Armed Forces.
1 Z- I ?---20 VS 57 j War or Dates
..p Place Bath I Hospital, Institution or
a City, own_ r Village C Street Address 22 �j c oc cj TQ, 1
Y 9 Ca).()�����,
Manner of Death
\Natural Cause El Accident El Homicide Ei Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Address
11s2.1 en ,Li Q-ee au_boNS\30.c.,1I3'1 1 z£o 1-f
Death Certificate Filed ,J i D ict Numbere is ter Number
_> Citycn r Village ��s`0v ry ' ) 18 c
Date I Cemetery or Crmatory
Burial I Z- I(9 ' 2o15 P( nl e. V-1 e ('Q'N`Q_A-r°.r
Address
•' LiCremation r /
Date Pace 2-�O c�
Removed
. Z❑Removal and/or Held
�.. and/or Address
>
' Hold
Q Date I Point of
•
Q Transportation. Shipment
a by Common Destination
Carrier
Disinterment Date ! Cemetery Address
Reinterment Date Cemetery Address
iai Permit Issued to _ i/ Registration Number
Name of Funeral Home _l R1�Xb12 f-x,U�L /'76NL 01130
Address
1/ C t 1C �;. (0 /JsC 0 l� y .
Name of Funeral Fffm MakingDisposition or to Whom I •
N" P
Remains are Shipped, If Other than Above
Address
f
giiili.. Permission is hereb granted to dispose of the human em ins described above aas indicated.
Date Issued 1c- I L l( Registrar of Vital-Statistics C_% .na-4...,---.
iiin i ture)
District Numbe (o,:cn Place '- 9'r5'
I certifythat the remains of the decedent identified above were disposed of in accord with this permit on:
P
W Date of Disposition 1 2/1 6/1 5'lace of Disposition Pine View Cemetery, Queensbury, NY
2 (address)
W •
Mohican 8A 4
£C (section) (lot number) (grave number) •
Name of Sexton or Person-in Charge of Premises Connie L. Goedert
CA
7 (please print)
W Signature Zaj 1 .,CalC Title Cemetery Superintendent
i - (over)
DOH-1555 (9/98)