Lebrun, Omer NEW YORK STATE DEPARTMENT OF HEALTH ; ir
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Omer Rosario Lebrun Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 9, 2012 78 War or Dates
H Place of Death Hospital, Institution or
ai City, Town or Village Hudson Falls Street Address 86 Boulevard
la Manner of Death r7r1
inj Natural Cause ❑ Accident ❑Homicide ❑ Suicide n Undetermined ri❑ Pending
0 Circumstances Investigation
ILI Medical Certifier Name Title
CI Philip Gara, M.D. Dr.
Address
Broadway Fort Edward, NY 12828
Death Certificate Filed District Number Register Number
City, Town eillage� J 4--e. :5 7�L, e/
El Burial Date Cemetery or Crematory
February 13, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
a, and/or Address
1-' Hold
Date Point of
„ ❑ Transportation Shipment
by Common Destination
CI' Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
ri ❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
1-- Remains are Shipped, If Other than Above
ram:
Address
w
". Permission is hereby granted to dispose of the human remains described above as indicated.
_, Date Issued - 13--20/a- Registrar of Vital Statistics .i
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`��,, 1 (signature)
District Number 7�/ Place 1)J ,,�� - w/ c-z,�L.2.cx.i ' 2 y)
I certify that the remains of the decedent identified above were dispose of in accordance with this permit on:
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uj• Date of Disposition #elei !it NI_ Place of Disposition ,r.cV l-, t'42ty-
;�,,�� (address)
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; (section) / _ (lot number)c (grave number)
r` ° Name of Sexton or P on in Charge Premises L t,)tr �';
Zr (please print)
LH Signature — Title CC ri r0A--C44
(over)
DOH-1555 (02/2004)