LaPorte, John N.
NEW YORK STATE DEPARTMENT OF HEALTH fr) b
Vital Records Section • it Burial - Transit Permit
Name First Middle Last Sex
John A. LaPorte Male
Date of Death Age If Veteran of U.S. Armed Forces,
2/6/2 01 2 5 9 War or Dates n/a
Place of Death Hospital, Institution or
ZCity, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death® Natural Cause ❑Accident 0 Homicide ElSuicide ri❑ Undetermined ❑Pending
CU Circumstances Investigation
iii Medical Certifier Name Title
0 Marvin Davidowitz, MD
Address
100 Park Street, Glens Falls, NY
Death Certificate Filed District Number Regit Number
City, Town or Village Glens Falls 5601
❑Burial Date Cemetery or Crematory
' 2/7/2012 Pine View Crematory
❑Entombment Address
;;Cremation Quaker Rd. Queensbury, NY 12804
Date Place Removed
Z❑Removal and/or Held
2and/or Address
H Hold
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0 Date Point of
CL N❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Frederick Bros Funeral Home 00619
Address
38422 NYS Route 37 Theresa, NY 13691
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Z Address
1r
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 2/'7 f`Z Registrar of Vital Statistics oLk�
V (signature//l)
District Number .5-6 0 ) Place 6 („2„, S c Ck n S H y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1-
Z it Date of Disposition Fel, 1i Zbi2 Place of Disposition eubo 6,4 .,,...,
W (address)
Cl)
CC (section) (lot number)r (grave number)
in Name of Sexton or P on in Charg of Premises 1 r,A-fit" s't"rtit
Z (please print)
w Signature �� Title 1,A11-id()-
(over)
DOH-1555 (02/2004)