LaVergne, James 05/23/2017 07:05 3153696942 PAGE 01/01
NEW YORK STATE DEPARTMENT OF HEALTH I
Vital Records Section Burial - Transit Permit
Name Firsliames Middle B. 11! Vergne Sex Male
Data§ifl& et6 Age. Ifyears If Veteran of U.S. Armed
ed Forces,
War or Oates
P ofw Deanor Nap t Webb Hospital, Institutionor
Street Address Fulton St
r o
Manner of Death Natural Cause �Accident �Homicide �Suicide Undetermined Pending
Circumstances Investigation
iii_
W Medical Certifier Name Title
ldi Michael Sikirica Medical Examiner
'. ;e4,412Pefroad St., Waterford, N Y 1218E
. .,,Pertific ., ' Distr t umber : ' Rt ister'.Number
�,Webb•�
ity, own.or...r age.
[]Burial Date 05/23/2017 I Cernetery or Crematory
ineryView Crematory
[]Entombment-Addre
rf Cremation wueensbury, NY
Date Place Removed
Q RemoVel and/or Held
•
• and/or
d/ord Address
HVI
Date Point of
inLJ Transportation Shipment
a by.Common Destination
Carrier •
r'Q Disinterment
Date Cemetery Address
El Renterment Date Cemetery Address
�' Permit Issued to Miller Funeral Home Rego 199 n Number
Name of Funeral Home _
AddrM57 NYS Rte 30, PO Box 718, Indian Lake, NY 12842 .
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
5
Permission is herebygranted to dispose of the human re aina described abov s,indicated
05/21/2017
Date issued Registrar of Vital Statistics A k
(ai nature)
District.Number 21p-' 0-7 Place_ Webb 1 t 1 �� W
i certify that the remains of the decedent identified above were disposed of in accordance with this permit on.
t
tii Date of Disposition_ S i2N)I-) _ Place of Disposition . go e V Co . ®to,,,_
W (address) •
al
cr (section) (let nurnbsr) (grave number)
coName of Sexton or Person in Charge of P emises
E ��r> �'�` e�at�'
,�. (pi se print)
. Signature a .Z. j Title 1061117,
(over)
DOH-1555 (02/2004) .
I