O'Keefe, Lawrence !ii' 0 216
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lawrence O'Keefe Male
Date of Death Age If Veteran of U.S. Armed Forces,
A s ril 15, 2015 70 War or Dates
Place of Death Hospital, Institution or
;;; City, Town or Village Glens Falls Street Address 18 May Street
:: Manner of Death X Natural Cause I 'Accident Homicide Suicide Undetermined 1 Pending
rX Circumstances Investigation
Medical Certifier Name Title
r' Sheryl Salerno NP
Address
161 Carey Road,Queensbury,NY 12804
4Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 2 ®`-]
El Burial Date Cemetery or Crematory
April 21, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Cn Removal and/or Held
I— Hold
Address
Hold
0 Date Point of
NTransportation Shipment
p" by Common Destination
Carrier
Disinterment Date Cemetery Address
I
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 401443
Address
53 Quaker 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.
0 Date Issued 14 / i 1 115 Registrar of Vital Statistics L� -Ovv' v — 1
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tu Date of Disposition en tJlc Place of Disposition ZU—J C+itof,--
W (address)
U)
Ct (section) A (lot nurser) (grave number)
aName of Sexton or Person in Charge of Premises ,., �.cr-sct"
Z (please print)
W
Signature Title azvm4la
(over)
DOH-1555(02/2004)