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LaCross, Donald Joseph NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Donald Joseph LaCross I Male Date of Death Age If Veteran of U.S.Armed Forces, 05/04/2020 83 Years War or Dates 1953-1957 Place of Death Hospital,Institution or WCity,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc p Manner of Death ©Natural Cause Accident Homicide Suicide ❑Undetermined Pending W Circumstances Investigation W Medical Certifier Name Title John Quaresima MD Address 319 Broadway,Fort Edward Town,New York 12828 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 44 ❑Burial Date Cemetery,Crematory or Facility Name 05/06/2020 Pine View Crematorium Entombment Address X❑Cremation Queensbury Town,New York Donation z ❑Removal Date Place Removed and/or and/or Held ~ Hold Address CO) O d Date Point of Cl) Transportation Shipment p by Common Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition orto Whom Remains are Shipped,If Other than Above Address c W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/06/2020 Registrar of Vital Statistics Aimee Wakoney(ECectronicalySiyned) (signature/ District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 20 20 Place of Disposition -)1 Q ad (address/ 2 W Cl) (section/ (lot number) (grave number) IX g Name of Sexton or Perso jn Ch a of Pre ' es /please print/ W Title Signature DOH-1555(07/18)p 1 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# 1 .