LaFlash, Sean 41 ILA
NEW YORK STATE DEPARTMENT OF HEALTH �
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Sean M. LaFlash Male
gi Date of Death Age If Veteran of U.S. Armed Forces,
March 26, 2011 1 7 yrs. War or Dates n/a
Place of Death Hospital, Institution or
Z City, Town or Villagrelens Falls Street Address Glens Falls Hospital
Manner of Death ❑Natural Cause x❑Accident El Homicide El Suicide riUndetermined ❑Pending
Circumstances Investigation
119 Medical Certifier Name Title
0 Timothy Murphy, Coroner/ Paul Bachman, MD.
Address
52 Haviland Ave. , Glens Falls, NY. 12801
iiig Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 /
Date Cemetery or Crematory
❑Burial March 28, 2011 PineView Crematorium
Address
X Cremation Queensbury, NY. 12804
Date Place Removed
0❑Removal and/or Held
-- and/or Address
Hold
0 Date Point of
N0 Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Re i tration Number
Name of Funeral Home Mason Funeral Home 0 T 1 3 6
illi Address
PO. Box 277, Fort Ann, NY. 12827
iiilig Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ini Permission is hereby granted to dispose of the human remains descr' ed above s indi e .
Date Issued 0 3/2 8/2 01 1 Registrar of Vital Statistics �L ‘tri.
�
(signature)
District Number 5601 Place City of Glens Falls, NY.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 3-12 -II Place of Disposition fvu,1Li.r l.rrrn.,i f or*0,
2 (address)
LU
N
c (section) fl (lot n er) (grave number)
GName of Sexton or Person in Charg e o Premises ` r,�} �„ ='e'+�+
g (please print) Y
44 SignatureAk,-- Title CiaG n'1410t,
(over)
DOH-1555 (9/98)