Loading...
LaRock, Olga NEW YORK STATE DEPARTMENT OF HEALTH It 101 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Olga Patricia LaRock Female Date of Death Age If Veteran of U.S. Armed Forces, February 19, 2012 82 War or Dates Placeath Hospital, Institution or =,o City, own 1 Village Fort Edward Street Address Fort Hudson Nursing Home =z _ Manner of Death FriNatural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title Philip J. Gara, Dr. Address 318 Broadway Fort Edward 12828 Death Certificate Filed District Number Register tuber City, Town or Village S7ISS ❑Burial Date Cemetery or Crematory February 21, 2012 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M.B. Kilmer Funeral Home 01078 Address 136 Main Street, South Glens Falls NY 12803 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the hum ai .descri e above as in icated. Date Issued mil egistrar of Vital Statis 'cs 1 (signature)tu r)District Numbe T' Place -4AJ 0/ 10 a0 I certify that the remains of the decedent identified above were disposed in accordance with this permit on: Date of Disposition 02/21/2012 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) r (lot number) (grave number) Name of Sexton or Per on in Charge of Premises l Lt,si�l4> 3thntik (please print) Signature Title Can► i cXl. (over) DOH-1555(02/2004)