LaRock, Ronald t . % { 37
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
rcii Name First Middle Last Sex
Ronald LaRock Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 8,2017 63 War or Dates
4 Place of Death Hospital, Institution or
y City, Town or Village Fort Edward, NY Street Address Fort Hudson Nursing Home
' :d Manner of Death n Natural Cause n Accident n Homicide n Suicide n Undetermined pi Pending
` Circumstances Investigation
. " Medical Certifier Name Title
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Address.
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Death Certificate Filed District Number Register pumber
City, Town or Village Fort Edward,NY 5755
❑Burial Date Cemetery or Crematory
❑Entombment January 11, 2017 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z ❑Removal and/or Held
9 and/or Address
Hold
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O Date Point of
NH Transportation Shipment
pp by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
VPermit Issued to Registration Number
j' Name of Funeral Home Regan Denny Stafford Funeral Home 01443
. Address
,,; 53 Quaker Road, Queensbury,NY 12804
0 Name of Funeral Firm Making Disposition or to Whom
` Remains are Shipped, If Other than Above
Address
,;f Permission is hereby granted to dispose of the human ins described ove s indicated.
r
Date Issued - �� Registrar of Vital Statistics C r
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signature)
f District Number 5- 55 Place �,0-� (,v 0(
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t— I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Q (t
W Date of Disposition f i j1 In Place of Disposition �,OYkr61*(11PL-1
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(address)
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W (section) //(lot number) c (grave number)
Q Name of Sexton or Person in Charge of Premises / Ar4 _) L:.,' I'
Z (ple se print)
W Signature /a_ Title 1FlU4 6
(over)
DOH-1555(02/2004)