Havens Sr, Larry NEW YORK STATE DEPARTMENT OF HEALTH . 1 ICTL
Vital Records Section Burial - Transit Permit
' Name First Middle Last Sex
,: ; Larry E. Havens,Sr. Male
SI Date of Death Age If Veteran of U.S. Armed Forces,
r< February 4, 2015 73 War or Dates Army
.)"" Place of Death Hospital, Institution or
City, Town or Village Town of Luzerne Street Address 126 Hartman Loop
141
Manner of Death Undetermined Pending
X Natural Cause ❑Accident I I Homicide n Suicide n n' Circumstances Investigation
w; Medical Certifier Name Title
Aqeel Gillani,MD
Address
t% Glens Fall,NY
'f'' Death Certificate Filed District Number Register Number
;:> City, Town or Village Town of Luzerne
❑Burial Date Cemetery or Crematory
February 6, 2015 Pine View Crematorium
El Entombment Address
0 Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ ri❑Removal and/or Held
12 and/or Address
H Hold
N
0 Date Point of
5 n Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
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
b- Remains are Shipped, If Other than Above
Address
1
Permission is hereby granted to dispose of the human re ai s descri d abov as 'ndicated.
Date Issued -_- 0/5 Registrar of Vital Statistics .� k.._. 4z., z
,, (signature)
}
District Number 6--- Place Town of Luzerne
VI
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition i11/l ' Place of Disposition Zill-i C,,,,4r,....-
2 (address)
W
co
cc (section) a (lot number) (grave number)
O
G Name of Sexton or Perso in Char a of Premises i .
W 1 (pl ase print)
Signature Title COCP11
(over)
DOH-1555(02/2004)