LaPine Jr, Charles NEW YORK STATE DEPARTMENT OF HEALTgl-I `' ti LI it O
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Charles R LaPine Jr Male
Date of Death Age If Veteran of U.S. Armed Forces,
07/31/2013 79 years War or Dates 1953 -55
Place of Death Hospital, Institution or
E City, TowXX 'iI XX Glens Falls Street Address Glens Falls Hospital
0 Manner of DeathX157'1tural Cause El Accident ❑Homicide ❑Suicide ElUndetermined ❑Pending
ILi
Circumstances Investigation
ill Medical Certifier Name Title
CI Noelle Stevens M D
Address
100 Broad Street Glens Falls, N Y 12801 .
Death Certificate Filed District Number Register Number
City, TowXXxj(iIXX Glens Falls 5601 330
❑Burial Date Cemetery or Crematory
['Entombment Pine View Crematorium
Address
i y1C,�emation Queensbury, NY 12804
Date Place Removed
Removal and/or Held
2 and/or
� Address
Hold
0 Date Point of
❑Transportation • Shipment
.a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton- Mc Dermott Funeral Home, Inc. 00141
Address
9 Pine Street Chestertown, N Y 12817
Eiiiil Name of Funeral Firm Making Disposition or to Whom
i Remains are Shipped, If Other than Above
a Address
cr
III
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/02/2013 Registrar of Vital Statistics (A) CAR. W
(signature
District Number 5601 Place Glens Falls) iVy
a:: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILt Date of Disposition c/c/ti Place of Disposition ,e01.A.v Ct crew
(address)
111
tfl
ICE (section) (lot ber) cc (grave number)
DName of Sexton or Person - Charge of P misesul �t'� �.JP„ tf
(please print)
Signature Title CaCMATQ
(over)
DOH-1555 (02/2004)