Hickey, Laurence 4 't T" 7J
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Laurence R. Hickey Male
Date of Death Age If Veteran of U.S. Armed Forces,
01/30/2Q16 70 years _ War or Dates
1- Place of Death ' Hospital, Institution or
Z City, T Street Address
W ° k' �X Saratoga-. rings Saraton
WManner of Death El Natural Cause 11 Accident 0 Homicide ❑Suicide 11 Undetermined ❑Pending
Circumstances Investigation
i Ai Medical Certifier Name Title
CI
Joshua2amer M D
Address
211 Church Street, Saratoga Springs, N Y 12866
Death Certificate Filed District Number Register Number
City, Tc VA* x Saratoga Springs 4501 RR
❑Burial Date Cemetery or Crematory
['Entombment Address
Pinevipw Crematorium
Address
[Cremation Queensbury N Y
Date Place Removed
Z El Removal and/or Held
21-1and/or Address
Hold
0 Date Point of
d' Trans ortation
❑ p Shipment
d by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
Address
7 Sherman Ave, Corinth, New York 12822
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above
2 Address
Ili
CL Permission is hereby granted to dispose of the human remain ib ab v as i dicated.
Date Issued 02/01/2016 Registrar of Vital Statistics 1 -
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition ` 4-16 Place of Disposition �yix, V ZW Gf c to fy
2 (address)
ul
pCC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises _ Zi c,Medy &.0 fe-S
Z (please print)
iii Signature - Title C ft/WI4c r
(over)
DOH-1555 (02/2004)