Laraway, James NEW YORK STATE DEPARTMENT OF HEALTH 'r ff 7
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James P. Laraway Male
Date of Death Age If Veteran of U.S.Armed Forces,
F October 16, 2015 50 War or Dates
Z Place of Death Hospital,Institution or
W City,Town,or Village Whitehall Street Address His home
o Manner of Death 0 Natural Cause ❑ Accident ❑Homicide ❑Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
G Medical Certifier Name Title
W Mrs. Ruth Scribner Coroner
0 Address
Whitehall, NY 12887
Death Certificate Filed District Number 5 '�U y� / Register Number
City,Town or Village Whitehall V 6
❑Burial Date Cemetery or Crematory
October 20, 2015 Pineview Crematorium
❑Entombment Address
[ICremation Town of Queensbury Queensbury, NY 12804
2 Date Place Removed
0 ❑Removal and/or Held
as and/or Address •
I" Hold
0 Date Point of
0 ❑Transportation Shipment
L by Common Destination
Carrier
Date Cemetery Address
❑Disinterment
El ❑Renterment Date Cemetery Address
Permit Issued to Registration Number •
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
f= Name of Funeral Firm Making Disposition or to Whom
cc
ccRemains are Shipped, If Other than Above
W Address
0.
Permission is hereby granted to dispose of the human remains described above�as indicated.
Date Issued lb—i 9-�o t S Registrar of Vital Statistics a. Y��I� tfi-
(signature)
k.
District Number 516 if Place Whitehall,New York
H I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 10/20/2015 Place of Disposition Pineview Crematorium
2 (address)
W
41)
O (section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises 0-,,�/�-, S ti.ii
2 ►(please print)
L.
Signature �f .,e Title t a'+d
(over)
DOH-1555 (02/2004)