LaRock, Elias 09/19/2017 13:12 _ 15184895632 -TEBBUTT FREDERICK PAGt al
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial . Transit Permit
— _
Name First Middle Last sex
ELIAS STEVEN LAROCK Male
Date of Death Age If Veteran of U.S.Armed Forces,
September 17.2017 5 War or Dates
Place of Death Hospital, Institution or
City, Town or Village ALBANY Street Address ALBANY MEDICAL CENTER
Manner of Death Natural Cause [l Accident Homicide E]Suicide E]Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
GEOFFRY GILLESPIE MD
-- -- -Address _
43 NEW SCOTLAND AVENUE,ALBANY,NY 12200
Death Certificate Filed j Register Number
City,Town or Village ALBANY 0101 2011
®Burial Date Cemetery or Crematory
September 19,2017 SHAARAY TEFLIA CEMETERY
❑Entombment Address
[]cremation QUEENSSURY,NY
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Paint of
Transportation Shipment
by Common Destination
Carrier
Disinterment Data Cemetery Address
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home REGAN DENNY STAFFORO FUNERAL,HOME 101443
Address
53 QUAKER ROAD,QUEENSBURY,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human ins descri ove as indicated.
Date Issued September 19,2017 Registrar of Vital Statistics
signature)
District Number 0101 Place CITY OF ALBANY
I certify that the remains of the decedent identified above were disposed of in accordance With this permit on:
Date of Disposition l_> /`7 7 Place of Disposition
-� '(ifddresss)
{section) #at number) (gra►o number)
Name of Sexton or ersnn in Charge of Premises zo, a -r-
�/" -I/ (please print)
Signature Title
(over)
DOH-1555(02/20")