LaVergne, Terry tcl
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Terry S. LaVergne Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 1,2012 53 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death Natural Cause X Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
G Medical Certifier Name Title
Michael Sikirica
Address
50 Broad St.,Waterford,NY 12188
Death Certificate Filed District Number I Register Number
City, Town or Village Glens Falls 5601 I _5.5C�
❑Burial Date Cemetery or Crematory
December 10,2012 Pine View Crematory
❑Entombment Address
❑x Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
Hold
U)
O Date Point of
EL Transportation Shipment
to
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
2 Address
tY
W
a
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued I Zl I J '2. Registrar of Vital Statistics W
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 12-It-It Place of Disposition 4? puj re/ 4tr;1.s.
(address)
U)
CL
(section) -- (lot number) S (grave number)
Z ?please Name of Sexton or Person in Charge of Premises t'J�p print) Cgri�W
Signature Title C2EM1`t t�PC
(over)
DOH-1555 (02/2004)