LaHart, Russell qlt
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
RUSSELL J. LaHART MALE
Date of Death Age If Veteran of U.S. Armed Forces,
SEPT. 24, 2011 80 War or Dates KOREAN
Place of Death Hospital, Institution or
City, Town or Village • Q[JEENSBURY Street Address THE PINES NURSING HOME
• Manner of Death ®Natural Cause ❑Accident El Homicide ❑Suicide ❑ Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
WILLIAM M. PARKER, MD
Address
170 WARREN STREET, GLENS FALLS, NY
Death Certificate Filed District Number Register Number
City, Town or Village
LIBurial Date Cemetery or Crematory
SEPT. 28, 2_011 PINE VIEW CREMATORY
Entombment Address
®Cremation Q[1EENSB[JRY, NY
Date Place Removed
Z Removal and/or Held
❑and/or
� Address
Cl)) Hold
O Date Point of
Transportation Shipment
N ❑
O by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 4• B. CLARK, INC. 01094
Address
2310 SARANAC AVE. , LAKE PLACID, NY 12946
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
'; Address
PL
Permission is hereby granted to dispose of the human remains descriis d -bove a iodic
Date Issued 09/26/11 Registrar of Vital Statistics
(signature)
District Number 5601 Place Q[JEENSB[JRY, ;STY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tLI Date of Disposition 9 In ((I Place of Disposition `c):+4 VtiJJ ery-d df)vti
(address)
111
j (section) 71 (lot num ') (grave number)
ci Name of Sexton or P rson in Charg of Premises r,s J•ht '
(please print)
Signature Title CAPAIW ,
(over)
DOH-1555 (02/2004)