Loading...
LaGoy, Roderick NEW YORK STATE DEPARTMENT OF HEALTH r - Vital Records Section Burial - Transit Permit Name First Mi c le Last Sex Roderick Teal, LaGoy Male Date of Death Age If Veteran of U.S. Armed Forces, October 12,2012 63 War or Dates Vietnam ice, Place of Death Hospital, Institution or 1City, Town or Village Bolton Street Address 815 Trout Lake Road 5 Manner of Death — Undetermined -Pending X Natural Cause Accident � 'Homicide Suicide W - - Circumstances ' Investigation t> in Medical Certifier Name Title Anthony Petracca Jr. Dr. Address 3 Iron Gate Center,Glens Falls,NY 12801 E Death Certificate Filed District Number Register Number City, Town or Village Bolton 5650 /3 ❑Burial Date Cemetery or Crematory 0 Entombment October 16,2012 Pine View Crematory Address ©Cremation 21 Quaker Rd., Queensbury, NY 12804 Date Place Removed Z Removal and/or Held 0 and/or Address H Hold CO 0 Date Point of N I. 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 Alexander-Baker Funeral Home 00035 Address 3809 Main Street,Warrensburg,NY 12885 Name of Funeral Firm Making Disposition or to Whom . - Remains are Shipped, If Other than Above Address 3' Permission is hereby granted to dispose of the human ains described above as indicated. Date Issued I a- /5-ao 1), Registrar of Vital Statistics :-Ci ,i,a,, ,ec... (signature) District Number 5650 Place Bolton I certify that the remains of the decedent identified above were disposed - in accordance with this permit on: w Date of Disposition 10,0-'L Place of Disposition ' „� w Crory-for Gf.t,,,., W (address) U) 0 (section) it (lot number) (grave number) ap Name of Sexton or Person in Charge of remises tj r,. .j 3t4.111- Z I (please print) W Signature Title Ca .t ldrTO(1.. (over) DOH-1555(02/2004)