Gonyea, Lawrence 4 V11/1
NEW YORK STATE DEPARTMENT OF I-`CALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lawrence Rolland Gonyea Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 2, 2014 72 War or Dates
,,. Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address 13 Fulton Street
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Manner of Death 0(l Natural Cause n Accident n Homicide Suicide 1 Undetermined n Pending
Circumstances Investigation
W Medical Certifier am �,\,� Title
Address
, C -1Q-1- -- 1 c._\1 inj 2—%0 1
Death Certificate Filed t District Number Register N umber
City, Town or Village Glens Falls,NY 5601 5 01
❑Burial Date Cemetery or Crematory
November 7,2014 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z El Removal and/or Held
and/or Address
f' Hold
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O Date Point of
N n Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment 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
W Remains are Shipped, If Other than Above
X Address
IZ
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Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Ili `-[ l I L-j Registrar of Vital Statistics 1/0 i`AA}re-\_e, uo
(signature)
District Number 5601 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 a Ao J(ki Place of Disposition ?At, LIL.1 Cr-s--'(cry
g (address)
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CZ (section) ,7 Cot tuber)(' (grave number)
pName of Sexton or Person in Charge of Premises ` r, _SD vp k
Z `� � (pi ase print)
W Signature ((/���@ Title ClZuoYj1t
(over)
DOH-1555(02/2004)