Levesque, Lawrence NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lawrence M Levesque Male
Date of Death Age If Veteran of U.S. Armed Forces,
11/16/2017 91 Years War or Dates 1946-1947
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause Accident D Homicide Suicide 0 Undetermined 0 Pending
Circumstances Investigation
Medical Certifier Name Title
Asim Chaudry MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 592
❑Burial Date Cemetery or Crematory
11/17/2017 Pine View Crematory
['Entombment Address
Cremation Queensbury Town, New York
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
"'* by Common Destination
Carrier
Date Cemetery Address
° El Disinterment
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
' Address
82 Broadway,Fort Edward,New York 12828
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 11/17/2017 Registrar of Vital Statistics p6ertACurtis EfectronicaaySigned"
(signature)
District Number Place
5601 Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Ili loin Place of Disposition
(address)
(section) A (lot.qumber) (grave number)
Name of Sexton or Person in Charge of Prem. es L 4r+�d �- �.sor
(pease prin
Signature Title GRitiMn T]i0L
(over)
DOH-1555 (02/2004)