LaMarque, Ronald NEW YORK STATE DEPARTMENT OF HEALTH
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Vital Records Section Burial - Transit Frermit
>`:i Name First Middle Last Sex •
Ronald LaMarque Male
Date of Death Age If Veteran of U.S. Armed Forces,
08/06/2013 74 years War or Dated 959- 1962
1 . Place of Death Hospital, Institution or
Cit)CXIIONIIXDf C OXGage City of Newburgh Street Addres€t Lukes Hospital
0 Manner of Dea,tp❑Natural Cause ❑Accident ❑Homicide El Suicide Undetermined El Pending
i Circumstances Investigation
0.
tu Medical Certifier Name Title
Ravel Manish M D
Address
313 South William St., Newburgh, N Y
Death Certificate Filed District Number Register Number
City,XlitNinXIMKage City Of Newburgh 3502 386 •
❑Burial Date Cemetery or Crematory
08/12/2013 Pine View Crematory
El Entombment Address ,
✓« ['Cremation Queensbury, N Y •
Date Place Removed
❑Removal and/or Held
and/or
Address�;;
3
Hold
0 Date Point of
t
Transportation Shipment
G" by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral HomM. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward, N Y 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ILI
Permission is hereby granted to dispose of the human remains des r' abo a as indicated.
Date Issued08/06/2013 Registrar of Vital Statistics O%.tu.e.. tkC
(signature)
giN District Numbn02 Place City Of Newburgh •
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
p bl N Ii Dispositioniat a.-.
tt� Date of Disposition , � Place of � cw
2 (address)
tti
VI
#C (section) tt number) C (grave number)
i Name of Sexton or Person "n Charge of P emises t r t
2 (piea�e print)
7-ISignature Title Caeli4Ta
(over)
DOH-1555 (02/2004)