Lawrence, JamesNEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
%: L LH
Burial - Transit Permit
Name First Middle Last Sex
James Lawrence Male
Date of Death Age If Veteran of U.S. Armed Forces,
9/19/2019 74 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Wilton Street Address 166 Ruggles Rd.
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Manner of Death FX-] Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
VCircumstances
Investigation
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Medical Certifier Name Title
Address
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Death Certificate Filed
District Number <S
RQster Number
City, Town or Village Wilton
4569
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❑ Burial
Date Cemetery or Crematory
❑ Entombment
September 20, 2019 _ Pine View Crematory _
Address
® Cremation
Quaker Road, Queensbury, NY 12804
Date Place Removed
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❑ Removal and/or Held
and/or Address
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Hold
N
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Date Point of
y❑Transportation
Shipment-
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by Common
_
Destination
Carrier
❑ Disinterment
Date
Cemetery Address
IF
Renterment
Date
Cemetery Address
Permit Issued to
Registration Number
Name of Funeral Home Regan & Denny Funeral Home
01444
Address
94 Saratoga Avenue, South Glens Falls, NY 12803 _— _—
Name of Funeral Firm Making Disposition or to Whom
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Remains are Shipped, If Other than Above
Address
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Permission is hereby granted to dispose of the human remains described above s Indic ted.
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Date Issued v2 G) Registrar of Vital Statistics
(sr ature)
District Number 4569 Place Wilton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Date of Disposition Place of Disposition
2
(address)
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Op
lot number) (grave number)
(section) AqLst-Allt
Name of Sexton or Person in Charge of Premises
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(pl se print)
Signature 4Title C elw—
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b)
012550
Receipt
Human remains of it- delivered on 20
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Pine View Cemetery -kepresendng th6 fuse ia ome named on burial permit
Official Funeral Directors Reg. or License #