LaGrange, John 4 410
NEW YORK STATE DEPARTMENT OF HEAL'H" Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
John E La6range Male
Date of Death Age If Veteran of U.S. Armed Forces,
9/ �8 years War or Dates 1152 - 1955
PlaceO of1 l ea/2�h12 Hospital, Institution or
Z City, To Vi .- Street Address
ki X i.�. X Glens F� Glens I HHos ital
13 Manner' th me, Natural Cause Accident ❑Homicide ❑Suicide ndet�rmmed Pending
t i v Circumstances Investigation
ui▪ Medical Certifier Name Title
Q
Suzanneddr annc M. Raycski M.D.
Warrensburg Health Center Main St. Warrensburg, NY
Death Certificate Filed District Number Register Number
City, Tow Ii yX Glen Falls 5601 428
❑Burial are- Cemetery or Crematory
❑Entombment Address09/20/2012 Pine View Crematorium
NCJemation Queensbury, NY 12804
Date Place Removed
❑Removal and/or Held
l and/or Address
F- Hold
O Date Point of
r2 0 Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Fdward I Kelly Funeral Home 00519
z Address
Schrnnn I ake N Y 12870
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
fr
it
t:
"` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/17/2012 Registrar of Vital Statistics 01., \st �) A
(signature) vv
District Number Place / tJ V I
5601 Glens Falls 1
j1
>.: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �
i Date of Disposition `1/1HJ,L Place of Disposition --RUA,' ( ?
�r jv
(address)
to
to
cc (section) number) (grave number)
ci Name of Sexton or Per on in Charg f Premises r,/ �e ,•J1t
(please print)
W.
Signature Title CIl' 11-
(over)
DOH-1555 (02/2004)