Lavalley, Perley Si god
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
et Perley Louis Lavalley •---- Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/04/2018 63 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village East Greenbush Town Street Address Rosewood Rehabilitation And Nursing Center
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined I Pending
Circumstances Investigation
q.
esi Medical Certifier Name Title
Maximo Valero MD
I. Address
at 284 Troy Rd,East Greenbush Town,New York 12061
Death Certificate Filed District Number Register Number
City, Town or Village East Greenbush Town 4152 142
- C Burial
Date Cemetery or Crematory
_ 10/09/2018 Pine View Crematory
Entombment_ Address
Cremation Queensbury Town, New York
Date Place Removed
Removal and/or Held
• and/or
Address
Hold
Date Point of
• Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
6.4
` Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;ra
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
4 Date Issued 10/09/2018 Registrar of Vital Statistics Kimberly Anne Car(ock(EfectronicaffySigned)
(signature)
ei District Number 4152 Place East Greenbush Town, New York
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 10110111 Place of Disposition
..Ili.., CM.,
(address)
(section) (lot nu a r) (grave number)
1 Name of Sexton or Person in Charge of Pr ises (please pri )4' - SM.
lit
Signature Title C011et-Dik
(over)
DOH-1555 (02/2004)