LaPorte, Herbert NEW YORK STATE DEPART-" EN',OF HEALTH
Vital Records Section Burial - Transit Permit t-(3�
Y= . Name First Middle Last Sex
Herbert Edward LaPorte Male
Date of Death Age If Veteran of U.S. Armed Forces,
''' June 10, 2015 88 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
CI Manner of Death ii1771 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
WI. Medical Certifier Name Title
0 Kenneth France, M Lb
:. Address
Death ificate Filed District Number Register Number
City Town r Village Foy-- -clv�cl(C'� 575 f b
❑Burial Date Cemetery or Crematory
June 12, 2015 Pine View Crematorium
401❑Entombment Address
Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
{ and/or Address
Hold
I MN
0) Date Point of
a ❑Transportation Shipment
CO by Common Destination
1:1 Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
,;pc. 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
2 Address
1'7 Permission is h reby granted to disp a of the human ins descri d b ve s dicated.
Date Issued e2 Registrar of Vital Statistics
(signature)
District Number 6756 Place d(Wtait a
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-
Date of Disposition 06/12/2015 Place of Disposition Quaker Road Queensbury,NY 12804
2. (address)
WI
r (section) (lot number)` (grave number)
pName of Sexton or Person in Cha ge of Premises L 4'�• . J+y"ky
(please print)
tll Signature Title l "'7 (,
(over)
DOH-1555 (02/2004)