LaRoche, Luan Viy
NEW YORK STATE DEPARTMENT OF HEALTH f V Vital Records Section Burial - Transit Permit
:::: Name First Middle Last Sex
sr. Luan Mary LaRoche Female
Date of Death Age If Veteran of U.S. Armed Forces,
j:r July 24, 2014 56 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Argyle Street Address Washington Center
6 Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
- Circumstances Investigation
Medical Certifier Name Title
• Jennifer Hayes,MD
s Address
▪ 4573 State Route 40,Argyle,NY j '09
is Death Certificate Filed District Number Register Number
City, Town or Village Argyle,NY I640 9 5-7�l) D7
❑Burial Date Cemetery or Crematory
July 28, 2014 Pine View Crematorium
❑Entombment Address
El Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
0
O Date Point of
O.
Transportation Shipment
'p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
::. Permit Issued to Registration Number
::r Name of Funeral Home Regan Denny Stafford Funeral Home 01443
▪::1 Address
::r.: 53 Quaker Road, Queensbury,NY 12804
: Name of Funeral Firm Making Disposition or to Whom
; : Remains are Shipped, If Other than Above
IAddress
` :: Permission is hereby granted to dispose of the human remains described above as indicated.
▪ Date Issued 7/Zk) EOM Registrar of Vital Statisticsj-kij I(y IYIL .-
(signature)
District Number 5 JSD Place Argyle,NY
I certify that the remains of the decedent identified above were disposed of in accordanceae,,A,-7
with this permit on:
W Date of Disposition ?a9-// Place of Disposition / /V/!_ �� 100y
111
(address)
N
ce
(section) �Q Wlot nu ber) (grave number)
el• Name of Sexton or ers in •" a„,e of Premises j2 it a✓7i%Yt
Z / (please ))
W Q[ 11
Signature Title (�d �,/L T(
(over)
DOH-1555(02/2004)