Golden, Larry NEW YORK STATE DEPARTMENT OF HEALTH It 3!'
Vital Records Section 4 Burial - Transit Permit
Name First Middle Last Sex
Larry F Golden Male
Date of Death Age If Veteran of U.S.Armed Forces,
1, January 14, 2013 58 War or Dates
Z Place of Death Hospital, Institution or
W City,Town,or Village Glens Falls Street Address Glens Falls Hospital
G Manner of Death ❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ® Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Dr. Paul Bachman, M.D. MD
0 Address
3767 Main Street, Warrensburg, NY 12885
Death Certificate Filed District Number_ �i � / Register um
City,Town or Village Glens Falls C
❑Burial Date Cemetery or Crematory
January 18, 2013 Pineview Crematorium
❑Entombment Address
0 Cremation Quaker Road Queensbury, NY 12804
Date Place Removed
0 ❑Removal and/or Held
and/or Address
I' Hold
0 Date Point of
0 ❑Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
o ❑Disinterment
❑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
F= Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
ft
W Address
0.
Permission is her by ranted to dispose of the huma(remain describe above as ind'
Date Issued ` / Registrar of Vital Statistics p o _!/
g e7Z X z
(signature)
District Number L0 D/ Place Glens Falls,Ne York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 01/18/2013 Place of Disposition Pineview Crematorium
2 (address)
W
N
0 (section) i (lot number), (grave number)
O Name of Sexton or Person in Charge of Premises ns r ea
W / (Tease print)
Signature L — Title Cti1i1' .
(over)
DOH-1555 (02/2004)