LaRose, Kevin wcvv YUKK STATE DEPARTMENT OF HEALTH - ( -111 t"I. �
Vital Records Section Burial - Transit ermit
Name First Middle Last Sex
Kevin M LaRose Male
Date of Death Age If Veteran of U.S.Armed Forces,
F. December 28, 2013 53 . War or Dates no
2 Place of Death Hospital, Institution or •
W City,Town,or Village Glens Falls Street Address Glens Falls Hospital
Q Manner of Death El Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W Shahid Ahmed MD
0 Address
100 Park Street, Glens Falls New York 12801
Death Certificate Filed District Number j Register Number
City,Town or Village Glens Falls b { ,� 6�
❑Burial Date Cemetery or Crematory
January 2, 2014 Pineview Crematorium
0 Entombment Address
0 Cremation Queensbury, New York Queensbury, NY 12804
Date Place Removed
0 0 Removal and/or Held
- and/or Address
l' Hold
0. Date Point of
0 0 Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
6 0 Disinterment
0 Reinterment Date Cemetery Address
•
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
Name of Funeral Firm Making Disposition or to Whom
I-
,, Remains are Shipped, If Other than Above
W Address
0.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 2) 31 f 43 Registrar of Vital Statistics Lx'1A4Y--.2 A..)-- "'"
(signature)
District Number .56°1 Place Glens Falls,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-
W Date of Disposition Place of Disposition Pineview Crematorium
(address)
W
Irt
o (section) (lot number) (grave number)
a Name of Sexton or Person in Charge of Premises
Z (please print)
W Title
Signature
(over)
DOH-1555 (02/2004)