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LaFreniere, Darren NEW YORK STATE DEPARTMENT OF HEALTH Z 3 S Vital Records Section Burial - Transit Permit Name First Middle Last Sex Darren LaFreniere Male Date of Death Age If Veteran of U.S. Armed Forces, May 3, 2011 �J War or Dates Place of Death Hospital, Institution or City, Town or Village Hudson Falls Street Address VAughn Road Manner of Death mNatural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri 1-1 Pending CircumstancesInvestigation Medical Certifier Name Title Ageel Gillani, M.D. Dr. Address 100 Park Street, Pryne Pavillian Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village 576, % 0 '7 ❑Burial Date Cemetery or Crematory May 5, 2011 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 ❑ Removal Date Place Removed and/or and/or Held Hold Address Date Point of ❑Transportation Shipment by Common Destination Carrier Date Cemetery Address ❑ Disinterment ❑ 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 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/04/2011 Registrar of Vital Statistics (signature) District Number 5762 Place Town of Kingsbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition ,j-6-ti Place of Disposition N U i c� Cr- (address) (section) ` 1 (lot nu er) (grave number) Name of Sexton or Pers n in Charge of remises L h ±p14f v.itt (please print) Signature t Title aki)PTOt- 9 i (over) DOH-1555 (02/2004)