Lawrence, William v 5�
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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
William O. Lawrence Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 15,2011 79 War or Dates Korean
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death I xl Natural Cause Accident Homicide Suicide I I Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Daniel Way MD
MIEN,North Creek,NY 12853
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls,NY 5601 �cr
❑Burial Date Cemetery or Crematory
May 18,2011 Pine View CrematoD Entombment ry
Address
❑x Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z
I I Removal and/or Held
and/or Address
F" Hold
CO
0 Date Point of
NI I Transportation Shipment
p by Common Destination
Carrier
I Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped, If Other than Above
2 Address
CZ
W
a
Permission is hereby granted to dispose of the human remains described above ainddicated.
Date Issued 05/ /ZD// Registrar of Vital Statistics a
(signature)
District Number 5601 Place Glens Falls,NY
I-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 5'161-1( Place of Disposition 19"it.u,o Cry tvr+i,e
2 (address)
W
O (section) (lot numbs 7 (grave number)
Name of Sexton or Pers n in Charge Premises At:irlitir s2.4.41
(please print)
z
w 41L Title Cit it1�Q
Signature
(over)
DOH-1555(02/2004)