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Lafreniere, David if NEW YORK STATE DEPARTMENT OF HEALTH 41, Vital Records Section Burial - Transit Permit `., , Name First Middle Last Sex 1, David Lafreniere Male r Date of Death Age If Veteran of U.S. Armed Forces, August 24,2012 60 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls, NY Street Address Glens Falls Hospital v; Manner of Deathwki Natural Cause n Accident Homicide Suicide Undetermined n Pending Circumstances Investigation '_ Medical Certifier �Ne i\ � M� Title �, Address Death Certificate Filed District umber Register Number r City, Town or Village Glens Falls,NY 5601 1 G .� ❑Burial Date Cemetery or Crematory ❑Entombment August 29,2012 Pine View Crematorium Address ©Cremation 21 Quaker Road,Queensbury,NY 12804 Date Place Removed z Removal and/or Held and/or Address F" Hold N 0 Date Point of g3 Transportation Shipment p by Common Destination Carrier El Disinterment Date Cemetery Address El Renterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 r < Address 407 Bay Road, Queensbury,NY 12804 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 human remains described above as indicated. Date Issued SS12Sl e Z-. Registrar of Vital Statistics 11\} (signature) District Number 5601 Place Glens Falls,NY I certify that the remains of the decedent identified above were disposede��of in accordance with this permit on: Date of Disposition $-3d1Z, Place of Disposition ��rw►/�crJ Ccr*4o �.... W (address) U) re Q0 (section) /J/ - (lot number) (grave number) Name of Sexton or Person in Charge of Premises (/�i/,r,�'�'�,r�'I 5,,,,,/� Z ►(please print) W Signature atir..E. Title CrtR, mfi oQ (over) DOH-1555(02/2004)