LaPier, John NEW YORK STATE DEPARTMENT OF HEALTH r ��
Vital Records Section ` Burial - Transit Permit
Name First Middle Last Sex
John H. LaPier Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/77/9011 60 years War or Dates
Place of Death Hospital, Institution or
ii City, To Street Address
�'��l(��3��X Saratoga S rings Sarato Hospital
Manner of Death L.j natural Cause Springs
Accident 0 Homicide Suicide fl Undetermined Pending
III �--V� Circumstances Investigation
La Medical Certifier Name Title
44 RodnPy Ying MD
Address
59 Myrtle Street Saratoga Springs, Ny
Death Certificate Filed District Number Register Number
riii City, ToWRVKVji WRXX Saratoga Springs 4501 144
DBurial Date Cemetery or Crematory
❑Entombment 03/29/2011 Pineview Crematorium
Address
[.Cremation Queensbury N Y
Date Place Removed
Z Removal and/or Held
t ❑and; /or Address
Hold
Q Date Point of
Cti Transportation❑ p Shipment
iQ by Common Destination
Carrier
Vi
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00442
«< Address
7 Sherman Ave, Corinth, New York 12822
pii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
re
II
C` Permission is hereby granted to dispose of the human remain rib abg36, as- dicated
01 Date Issued 03/28/2011 Registrar of Vital Statistics
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance� with this permit on:
til Date of Disposition 3--3;;-ii Place of Disposition Punt U'8w U. t t l4CC,r,i,
(address)
Ill
CC (section)7 a (lot nu (grave number)
p Name of Sexton or Per i r of Premises (%a on in Char r t.i,t4t
(please print)
Signature 7 +i. Title C(C-PIli
(over)
DOH-1555 (02/2004)