Lavigne, Travis NEW YORK STATE DEPARTMENT OF HEALR-I_ eNt �'
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Travis Justin Lavigne Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 1, 2018 42 War or Dates
Place of Death Hospital, Institution or
W City, Town or Village Moreau Street Address 116 White Birch Estates
0 Manner of Death X❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide Undetermined Pending
Circumstances Investigation
111 Medical Certifier N met ?s n41(Te
t A ess C 3ttis �I�s S � (Z2
Death Certificate Filed l� District Nym _ r Regi r umber
City, Town or Village Moreau (l�j �
❑Burial Date Cemetery` or Crematory
May 7, 2018 Pine View Crematory
_❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
7;❑ Removal and/or Held
and/or Address
p Hold
0 Date Point of
W ❑Transportation Shipment
by Common Destination
G Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
ce
W Permission is h re y granted to dispose of the human remai scribe- . •o as indicated.
Date Issued _ g aRegistrar of Vital Statistics at,La_(
(sign8ture)
r J
District Number (ISO Place )I " l 1JY Pot Ai
ay ` /p/b al 2'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F-
M Date of Disposition 05/07/2018 Place of Disposition Quaker Road Queensbury,NY 12804
j (address)
W
Co
g. (section) /1(lot number) (grave number)
0 Name of Sexton or Person in Charge f Premises ` r .°'1*itf
r (p ase print)
W Signature s/ • - Title Ocfmr4,2
(over)
DOH-1555 (02/2004)