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LaRock Jr, Daniel NEW YORK STATE DEPARTMENT OF HEM_TH Vital Records Section Burial - Transit Permit q Name First Middle Last Sex : Daniel Robert LaRock Jr. Male re Date of Death Age If Veteran of U.S. Armed Forces, February 15, 2011 23 War or Dates Place of Death Hospital, Institution or City, Town or Village Fort Ann Street Address Buttermilk Falls Road & Rte 149 s Manner of Death❑Natural Cause El Accident ❑ Homicide ❑ Suicide Ell Undetermined ❑ Pending i' Circumstances Investigation �' Medical Certifier Name Title Max Crossman MD, Address North St. Granville, NY 12832 Death Certificate Filed District Number Register Number City, Town or Village ❑Burial Date Cemetery or Crematory February 22, 2011 Pine View Crematorium ❑Entombment Address .4 • © � Cremation Quaker Road Queensbury,NY 12804 Date Place Removed • ❑ Removal and/or Held and/or Address • Hold Date Point of ',T: 0 Transportation Shipment ,. by Common Destination Carrier 44 ❑ Disinterment Date Cemetery Address 14 � _❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00276 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 41 Name of Funeral Firm Making Disposition or to Whom 7 Remains are Shipped, If Other than Above Address is g�,... Pe::: is hereby granted to dispose of the human rem s descri above a . ated. . . W . --/� r Registrar of Vital Statistics , (signature) • District Number Place �,/ D I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 02/22/2011 Place of Disposition Quaker Road Queensbury,NY 12804 7 (address) (section) - ii (lot num ) (grave number) 4 Name of Sexton or Pe on in Char of Premises 0 t',Stuelltl' nmett Zi (please print) CSignature Title Cem14-�00 frig_ (over) DOH-1555 (02/2004)