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LaRoe, Bruce NEW YORK STATE DEPARTMENT OF HEALTH ; ellg Vital Records Section E> Burial - Transit Permit Name First Middl- • Last Sex Bruce Anthony"Sp s" -oe Male ; Date of Death Age Veteran of .` .rmed Forces, December 19, 2016 57 War or Dates F; Place of Death ospital, Insti ion or la City, Town or Village Fort Edward Streress 64 McCrea Street Manner of Death IZ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El Pending Circumstances Investigation Medical Certifier Name Title Address N 1 lbq lie Death Certificate Filed Ditric mbe Register Number City, Town or Village Fort Edward - ,510-4 1/ ❑Burial Date Cemetery or Crematory December 21, 2016 Pima View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Re 9 and/or Removal and/or He ..'; Hold Address ,,� Date Point of ❑Transportation Shipment by Common Destination Carrier ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number _: Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 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 e kiari s describe. abov a ' ated. Date Issued L9 c /16 Registrar of Vital Statistics 4 i Y ' / si n re) District Numberc8/65 Place I 7L �� `� `< I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 12/21/2016 Place of Disposition Quaker Road Queensbury,NY 12804 a (address) i (section) i'i (lot number (grave number) ' Name of Sexton or Person in Charge of -remises `�Os ,^ �J2ht6dr ((eease print) Si nature 11 I Title CR f TPt. 9 (over) DOH-1555 (02/2004)