LaCarrubba, John NEW YORK STATE DEPARTMENT OF HEALTH �i7
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John E. La Carrubba Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 15,2015 65 War or Dates
; Place of Death Hospital, Institution or
City, Town or Village Johnsburg Street Address 12 Thirteenth Lake Road
Manner of Death — Undetermined Pending
Natural Cause Accident Homicide Suicide
a Circumstances Investigation
W= Medical Certifier Name Title
'0. Robert W. Sponzo MD
Address
102 Park St.,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
• City, Town or Village T/O Johnsburg 5655 R .
❑Burial Date Cemetery or Crematory
November 17,2015 Pine View Crematory
11 Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
—_I— Hold
co
0 Date Point of
N L 1 Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
; Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
`° Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
E Remains are Shipped, If Other than Above
'„ ° Address
4,- Permission is hereby granted to dispose of the human re ' s describe above s i dicated.
Date Issued I1 ' r1'` 1� Registrar of Vital Statistics
(signature
District Number 5655 Place T/O Johnsburg
H �/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition li f igl'/r Place of Disposition tL, CfPrnCtoc,ai-..
W (address)
CO
fL (section) /��t/ (lot nu ber) (grave number)
pName of Sexton or Person in Char of Premises G Ar't t, ) 'ef
iZill (lease print)
Signature Title a2rAirg.------
(over)
DOH-1555 (02/2004)