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LaValley, Paul 4.--- bb -ii //9/ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Paul Joseph LaValley Male Date of Death Age If Veteran of U.S.Armed Forces, 02/17/2018 76 Years War or Dates 1959-1983 Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital riii Manner of Death©Natural Cause 0 Accident []Homicide 0 Suicide riUndetermined ri Pending Circumstances Investigation Medical Certifier fri IA Name Title Abigail Macomber PA Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 91 ❑Burial Date Cemetery or Crematory 02/20/2018 Pine View Crematory ❑Entombment Address ®Cremation Queensbury Town, New York Date Place Removed Removal - and/or Held and/orIM Address Hold a Date Point of �0 Transportation Shipment by Common Destination ® Carrier _ Disinterment Date Cemetery Address Reinterment0 Date Cemetery Address Permit Issued to Registration Number 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 - Address illf 1-11 Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/20/2018 Registrar of Vital Statistics i p6 rtA Curtis(EfectronicaffySigned) -✓ (signature) District Number 5601 Place Glens Falls, New York it I certify that the remains of the decedent identified above were disposed of in accordance e with this permit on: Date of Disposition ii 22 lig Place of Disposition f.,1' pit 00 (address) . ta o (section) of number) (grave number) S 'ea Name of Sexton or Person in Charge of Pre ises t (pie4ser= L hn+4 print) ;= Signature — i Title IRWs14fOI (over) DOH-1555 (02/2004)