McLaughlin, Maurice NEW YORK STATE DEPARTMENT OF HEALTH , "t # 3,-1 I
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Maurice Joseph McLaughlin Male
Date of Death Age If Veteran of U.S. Armed Forces,
07/p�1/2012 66 years War or Dates 1936-1966
H Place of Death Hospital, Institution or
Z City, Tow �_�/I Street Address
ILI X XX Clcns F Glcns F I s H s ital
i Manner o Ueath Natural Cause�Accident ❑Homicide 0 Suicide Pending
Circumstances Investigation
ui Medical Certifier Name Title
CI
Add eavid Footc M. D.
ss
340 A Main Street Hudson Falls, N Y 12839
Death Certificate Filed District Number Register Number
City, TowiescissVillaciaXX Glens Falls 5601 316
❑Burial Date Cemetery or Crematory
['Entombment 07/05/2012 PI^e View Cemetery
Address
❑Cemation Queensbury, NY 12804
Date Place Removed
❑
Removal and/or Held
and/or
Address
I:
0
Hold
0 Date Point of
ck 0 Transportation Shipment
•
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Mi Address
11 I afayette Street Oueensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
,'; Address
1r
Ili
Permission is hereby granted to dispose of the human remains described above as indicated.
1
Date Issued 07/05/2012 Registrar of Vital Statistics UOC i..9
(sign e)
District Number 5601 Place Glens Fails# N Y
' : I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI• Date of Disposition ")/6/1Z Place of Disposition 7 t-4Ulet/ (,rti-c/1atL_
2 (address)
ILEI
U,
CC (section) II (lot number) (grave number)
Name of Sexton or Person in Charge Premises ��4 Fir` J twill-
/4 (please print)
• Signature Title atif).M pri Olt
(over)
DOH-1555 (02/2004)