LaSure, Frederick NEW YORK STATE DEPARTMENT OF HEALTH tt 1162
Vital Records Section Burial - Transit Permit
i4
Name First Middle Last Sex
Frederick LaSure Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 8, 2013 79 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Easton Street Address Easton House for Capital District DDSO
Manner of Death 1=1 Natural Cause Li Accident 0 Homicide El Suicide 0 Undetermined 0 Pending
Circumstances Investigation
Medical Certifier Name Title
Paul Byron, Dr.
}d
Address
1 Myrtle Ave. Cambridge, NY 12816
; Death Certificate Filed District Number��'�1-.3 Register Number j Ci Town or Villa e Easton t.J <J
0 Burial Date Cemetery or Crematory
. August 12, 2013 Pine View Crematory
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
ri Removal and/or Held
and/or Address
Hold
Date Point of
0 Transportation Shipment
by Common Destination
Carrier
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
. ` Remains are Shipped, If Other than Above
� � PP
Address
i.,.
Permission is h-' s y granted to dispose of the human re ins described above as 'ndicat d.
?It Date Issued 61 9 `/ 3 Registrar of Vital Statistic ,,,, ,tt _err,,......,off_
(signature)
;,. - /
District Numbe '� 3 Place A� � �'7.V
I certify that the remains of the dec dent identified above were disposed of in accordance with this permit on:
Date of Disposition 08/12/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot pumber) cr (grave number)
Name of Sexton or Person i harge of Pre ises na
Signature (pl ase print)JQM Title CariMfirir2
(over)
DOH-1555 (02/2004)