LaFontaine, Roger NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Roger Lafontaine Male
Date of Death Age If Veteran of U.S. Armed Forces,
6/20/2018 76 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 28 Cederwood Drive
• Manner of Death n Natural Cause E Accident ❑Homicide n Suicide Undetermined n Pending
Circumstances Investigation
W Medical Certifier Name Title
O Anthony Petracca,MD
Address
3 Irongate Center,Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village 5 to S
®Burial Date Cemetery or Crematory
June 26,2018 Pine View Cemetery
El Entombment Address
El Cremation Quaker Road,Queensbury,NY 12804
Date Place Removed
ZO n Removal and/or Held
and/or Address
H Hold
co
O Date Point of
co Transportation Shipment
p by Common Destination
Carrier
U Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
t Address
W
a Permission is hereby granted to dispose of the human remainsn described above as indicated.
Date Issued to j a-D.1��12 Registrar of Vital Statistics �-+ A1)11-1
(signature)
District Number Sk,,5"7 Place Q1J c e,S IOU
J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 6/26/201 8 Place of Disposition Pine View Cemetery Oueensbury
(address)
u) Huron 8-C 1
(section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises Connie Goedert
, (N. (please print)
W Signature Title Cemetery Superintendent
(over)
DOH-1555(02/2004)