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LaPointe, Daniel 1)NEW YORK STATE DEPARTMENT OF HEALTH _t 7 Vital Records Section Burial - Transit Permit ,04 Name First Middle Last Sex Daniel W. LaPointe Male Date of Death Age If Veteran of U.S. Armed Forces, September 21, 2017 35 War or Dates Place of Death Hospital, Institution or City, Town or Village Kingsbury Street Address Manner of Death ❑Natural Cause X❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation 21 Medical Certifier Name Title N. Balasubraman, Address Death Certificate Filed District Number Register Number City, Town or Village Kingsbury 57(i j S ❑Burial Date Cemetery or Crematory September 25, 2017 Pine View Crematory ❑Entombment Address 4;©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed 7 ❑ Removal and/or Held and/or E Hold Address Date Point of Ix ❑Transportation Shipment by Common Destination Carrier ❑ Disinterment Date Cemetery Address Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 :a. Name of Funeral Firm Making Disposition or to Whom t Remains are Shipped, If Other than Above Address ye ut W. Permission is hereby granted to dispose of the human re d ribed above as indicated. Date Issued 9—is- a17 Registrar of Vital Statistics ( J--�--�_ �/ (signature) District Number o� Place wrL 4 __ _�° ----1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: tu Date of Disposition 09/25/2017 Place of Disposition Quaker Road Queensbury,NY 12804 (address) VA fg (section) A (lot number) (grave number) itt Name of Sexton or Person in Charge of P emises L 4ot,' J'^�1�el�/ (please print) f' Si nature G� Title tik rilk (over) DOH-1555 (02/2004)