LaVallee, Richard C, 1
NEW YORK STATE DEPARTMENT OF HEALTH �Z`
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Richard Leo LaVallee Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 25, 201 5 71 yrs. War or Dates No
Place of Death Town of Hospital, Institution or
City, Town or Village Ticonderoga Street Address 31 0 N.Y.S. Rte. 9N
Manner of Death®Natural Cause ElAccident ElHomicide -ElSuicide ElUndetermined ElPending
Lti Circumstances Investigation
in Medical Certifier Name Title
0 C. Francis Varga M.D.
Address
P.O. Box 768, Lake Placid, NY 12946
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 46
❑Burial Date Cemetery or Crematory
08/28/2015 Pine View Crematory
❑Entombment Address •
fl remation Queensbury, New York
Date Place Removed
Z�Removal and/or Held
i and/or
Address
Hold
0 Date Point of
CL El Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date- Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
ILI
Permission is hereby granted to dispose of the human rem scribed bove indicated.
Date Issued 0 8/27/201 5 Registrar of Vital Statistics ! ��� ti'�1
(sig ure)
District Number 1 564 Place Town of Ticonderoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
ILI Date of Disposition $/iglg( Place of Disposition C ro-;
2 (address)
ttif
C (section) j (lot numbe) (grave number)
ci Name of Sexton or Person in Ch rge of Premises L�+� y ^^ �•
please print)
Signature Title fa/4gt
(over)
DOH-1555 (02/2004)