LaLonde Sr, Jay A
NEW YORK STATE DEPARTMENT OF HEALTH • _`r LtSio
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jay Hull LaLonde Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 29, 2015 84 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death Natural Cause El Accident Homicide ❑ Suicide n Undetermined ri❑ Pending
11 Circumstances Investigation
Medical Certifier Name Title
a Philip J. Gara, Dr.
Address
�' 318 Broadway Fort Edward 12828
Death Certificate Filed District N mber Register Number
City, Town or Village Fort Edward 7; 6.7
,°❑Burial Date Cemetery or Crematory
July 1, 2015 Pine View Crematory
❑Entombment Address
v®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
. Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home- SGF 01078
y Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is h e granted to dispose of the human ins described a ove a indicated.
Date Issued , / Registrar of Vital Statisti p
,, „ ------ (signature)
i District Numbe,5z�"� Place 1/iWh �SJ��(1Q��2�V�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
pt`ne u .e W C('Oevrt4.4[or eV in
Date of Disposition 07/01/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
rp
i (section) t (lot number) (grave number)
Name of Sexton or Person in C arge of Premises f Cr'',® ky Su/6&lk
(please print)
Signaturel..-%may Title Crew.q- ory Art
(over)
DOH-1555 (02/2004)