Lafko, Anton 4_,
NEW YORK STATE DEPARTMENT OF HEALT - (----
Vital Records Section Burial - Transit Permit
Name First Middle , 3 Last Sex
Anton M. Lafko Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 29, 2012 79 War or Dates
i... Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
cManner of Death 'XI Natural Cause Accident r--Homicide Suicide Undetermined Pending
KLLI Circumstances - Investigation
CI Medical Certifier Name Title
a Philip J Gara,Jr,MD
Address
Fort Edward,NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601 38
❑Burial Date Cemetery or Crematory
ID Entombment January 31, 2012 i Pine View Crematory
Address
0 Cremation Quaker Road,Queensbury, NY _
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
N { i Transportation Shipment
p by Common Destination -H
Carrier
Disinterment Date j Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton-Healy Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
i�. Remains are Shipped, If Other than Above
2 Address
W
w
Permission is hereby granted to dispose of the human remains descr'b�ed abov as i c ted.
Date Issued c�/ 8p,2�/2-- Registrar of Vital Statistics i der/ L�
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LuDate of Disposition a -2,- joi? Place of Disposition (R ill e U .ems C(`evna4r,r f u.n�
2 (address)
LU
CO
IX (section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises y
z g I t h^� � / .`V n P���(please print)
w ---'" . s'- ( Title craw, �1
Signature •
(over)
DOH-1555(02/2004)
I