LaRock Sr, Gary NEW YORK STATE DEPARTMENT OF HEAL I
Vital Records Se
ction Burial - `transit Permit
Name First Middle Last Sex
Gary Edward LaRock Sr Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/03/2015 65 years War or Dates
iiiii Place of Death Hospital, Institution or
W City, TcXXK 1Xi?IZAX Glens Falls Street Address Glens Falls Hospital
a Manner of Death 3 Natural Cause El Accident 0 Homicide ❑Suicide ❑Undetermined 0 Pending
W Circumstances Investigation
iji▪ Medical Certifier Name Title
G Daniel Way M. D.
Addres
100 'ark Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, ToW dk'NOW Glens Falls 5601 126
❑Burial Date Cemetery or Crematory
03/06/2015 Pine View Crematory
❑Entombment Address
'ja 3Cremation Queensbury, NY
Date Place Removed
❑Removal and/or Held
�,; Address
CO
anHldd/or
O Date Point of
115 Eli Transportation , Shipment
0 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 01821
Address
11 Algonkin Street Ticonderoga, N Y
Name of Funeral Firm Making Disposition or to Whom
# Remains are Shipped, If Other than Above
• Address
Ill
a;` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/06/2015 Registrar of Vital Statistics (")O AJrYN.2
(signatur )
District Number 5601 Place Glens Falls; Mg
` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k 'f
ill Date of Disposition 3Ilo)�5- Place of Disposition ?gilt.� C;/hem-,
2 (address)
IU
to
ix (section) j (lot num er) (grave number)
Name of Sexton or Person in Charge of Premises `'�r• '4''
Z lease print)
Signature -- Title (iikin WA.
(over)
DOH-1555 (02/2004)