LaBarre, James NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
..:.: James F. LaBarre Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 6, 2015 81 War or Dates 1953- 1955
gPlace of Death Hospital, Institution or
City, Town or Village Ft. Edward Street Address Fort Hudson Nursing Home
▪ Manner of Death X Natural Cause 1 I Accident Homicide Suicide Undetermined Pending
IP Circumstances Investigation
Medical Certifier Name Title
. Carrie Miren RPAC
;... Address
j;19 Carey Road,Queensbury,NY 12804
::j.; Death Certificate Filed District Number Registe umber
.
City, Town or Village Fort Edward 5755
,❑Burial Date Cemetery or Crematory
January 8, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ I i Removal and/or Held
and/or Address
Hold
Cl)
O Date Point of
Q.
Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
:r;. Permit Issued to Registration Number
f� Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
: ' 53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
' : Permission is h eb granted to dispose of the human re ains described bove s indicated.
Date Issued / / Registrar of Vital Statistic
signature)
District Number 5755 Place Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition I /ilis- Place of Disposition gaceL Cam.-tire,,,
2 (address)
W
co
w (section) 4 (lot number) (grave number)
Q ,�Name of Sexton or Person in Charge of Premises L�� �,,, �e..44?'
Z (plebse print)
Signature...
IL
4- Title CI7t wfrik,
(over)
DOH-1555(02/2004)