LaFountain, Lawrence NEW YORK STATE DEPARTMENT OF HEALTH _l t0
Vital Records Section
' et Burial - Transit Permit
Name First Middle Last Sex
Lawrence Joseph LaFountain Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 7, 2011 80 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Wilton Street Address 83 Blanchard Road
-F Manner of Death El Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
°- Medical Certifier Name Title
Robert Sponzo, Dr.
Address
102 Park St. Glens Falls, NY 12801
Death Certificate Filed District Number , Register Numb r
City, Town or Village % '
-,0 Burial Date Cemetery or Crematory
August 10, 2011 Pine View
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
4 136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
, „ Remains are Shipped, If Other than Above
Address
i Permission is hereby granted to dispose of the human reins de l''ed bove as indicate
Date Issued 9 J, V( Registrar of Vital Statistics ( tt /
(si ture)
District Number / Place Au>� c' (1.);#0,6 ,Lc4�,,e) ',l/�_
/
I certify that the remains of the decedent identified above were disposed of in accorda ce with this permit on:
Date of Disposition 08/10/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) / (lot number (grave number)
Name of Sexton or Per n in Charge of remises G It(IS ) �'til A
(please print)
Signature '"�� Title Cit g,r lVe
(over)
DOH-1555 (02/2004)