Larrow, Martin NEVI YORK STATE DEPARTMENT OF HEALTH r 0 73O
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Martin Joseph Larrow Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 4, 2015 90 War or Dates
ZPlace of Death Hospital, Institution or
W j City, Town or Village Moreau Street Address 9 Robert Rogers Ave
❑ Manner of Death 0 Natural Cause ❑ Accident 0 Homicide 0 Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
Douglas Dennett, M.D
Address
84 Broad Street Glens Falls, NY 12801
Death Certificate Filed Dist N�,m Regis r Number
City, Town or Village S(p er (�
❑Burial Date Cemetery or Crematory
October 6, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
0and/or Address
H• Hold
Date Point of
nTransportation Shipment
CO by Common Destination
C Carrier
Date Cemetery Address
El Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
M Address
CC
Permission is hereby ranted to dispose of the human rema' escrib a ve s indicated.
Date Issued ,.c Registrar of Vital Statistics alay (s� nature)
District Number 1JW� Place �� j { Jac S ed , I I woo)" /0 Z
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 10/06/2015 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
W
U?
(section) ' �r (lot number) (grave number)
p Name of Sexton or Person in Charg of Premises St ii at t
(please print)
W Signature !/ Title (gI 1 -
(over)
DOH-1555 (02/2004)