Laurent, Jr. Eugene NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section f N Burial - Transit Permit
Name First Middle Last Sex
Eugene F. Laurent,Jr Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 5, 2012 79 War or Dates
H Place of Death I Hospital, Institution or
Z City, Town or Village Queensbury Street Address Westmount Health Facility
pManner of Death X Natural Cause ' 'Accident I }Homicide Suicide Undetermined 1 Pending
lAS Circumstances Investigation
w M cal Certifier Name Title
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Ctldre)is( (a
Death Ce ficate'Filed a-' er District Number R gister Number
City, Town or Village Queensbury,NY 5657 (Q
❑Burial Date Cemetery or Crematory
ID Entombment April 9, 2012 , Pine View Crematory
Address
ID Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
O and/or Address
�' Hold
rn
O Date Point of
NI i Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
W
a` Permission is hereby granted to dispose of the human r mains described above as indicated.
J
Date Issued 41 t:�.l &. Registrar of Vital Statistics Cl , .eLL�--„_,
signature)
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
11.1• Date of Disposition Avi(1U1 t011 Place of Disposition ?M Cvvi.LLU s{o(iw W (address)
N
fY
(section) A . , (loinumber) (grave number)
Q• Name of Sexton or Person in Charg of Premises ri cp r` Jlrh�f-
Z ir (please print)
W �I
Signature Title CQ J OC
(over)
DOH-1555(02/2004)