LaFountain, Edward s.
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Edward J. LaFountain Male
Date of Death Age If Veteran of U.S. Armed Forces,
�a December 15,2014 58 War or Dates
: Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
tili Manner of Death I XI Natural Cause i 1 Accident Ti Homicide n Suicide Undetermined n Pending
Circumstances Investigation
r Medical Certifier Name Title
Eric Pillemer MD
Address
GFH,Glens Falls,NY 12801
. Fe, Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601 5S.0
❑Burial Date Cemetery or Crematory
❑Entombment December 17,2014 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
t Hold
N
O Date Point of
rnn' P Transportation Shipment
a by Common Destination
Carrier
pi Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
*,°: Name of Funeral Home Alexander-Baker Funeral Home 00037
p > Address
3809 Main Street,Warrensburg,NY 12885
a.•: Name of Funeral Firm Making Disposition or to Whom
b Remains are Shipped, If Other than Above
'2 Address
rditi
fl;.:ry Permission is hereby granted to dispose of the human remains described above as indicated.
x
Date Issued 12-17-14 Registrar of Vital Statistics U0Cx. Q.
(signature)
::: : District Number s6,p 1 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition ii 1 ,J,y Place of Disposition -6, u,,,,, Crer tor,,,-N•N
W (address)
0 (section) (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises nk � .3_u,j't
W (pl ase print)
Signature &L AL Title fOE"(MIL
(over)
DOH-1555 (02/2004)