LaVia, Emil --- s #/gy
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
F ". Name First Middle Last Sex
Emil R. LaVia Male
Date of Death Age If Veteran of U.S. Armed Forces,02/23/2018 89 War or Dates Korean / } 5_J
Place of Death Hospital, Institution or
City, Town or Village Clifton Park,NY Street Address 23 Glenbrook Drive,Clifton Park,NY _
giManner of Death ❑X Natural Cause ❑Accident E Homicide n Suicide ❑Undetermined ❑Pending
Circumstances Investigation
�L3` Medical Certifier Name Title
` James Craig MD
Address
1 Tallowood Drive,Clifton Park,NY 12065
Death Certificate Filed District Numb I� Regislr dumber
City, Town or Village Clifton Park,NY yu�
❑Burial Date Cemetery or Crematory
D Entombment 02/28/2018 Pine View Crematory
Address
®Cremation Queensbury,NY
Date Place Removed
z ❑Removal and/or Held
2 and/or Address
H Hold
CO
0 Date Point of
tail n Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Renterment Date Cemetery Address
F Permit Issued to Registration Number
' ': Name of Funeral Home Regan Denny Stafford Funeral Home 01443
A Address
53 Quaker Rd.,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Ai
Remains are Shipped, If Other than Above
Address
Permission is hereby g anted to dispose of the human r mains des ibe above a n 'cnted.
Date Issued A A 1 oV Registrar of Vital Statistic _ �iry
(signature) i jA)
' District Number 1,�j 6j --a Place J iY n g P ,b)i
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I certify that the remains of the decedent identified above were dispos of in ac rdance with this permit on:
Z
g
v rt Date of Disposition Z/iiiig Place of Disposition -,ui •retbe
W (address)
CO
Ce (section) (lot numbert- (grave number)
pName of Sexton or Person in Charge of Premises �,, s-141'1
W (pl(Ltd—
print)
2
Signature Title /14-Mat
(over)
DOH-1555(02/2004)