Laroche, Michael NEW YORK STATE DEPARTMENT OF HEALTH ; # t ES—
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Michael Edward Laroche Female
Date of Death Age If Veteran of U.S. Armed Forces,
_ 8/8/2018 63 War or Dates_ n/a
E. Place of Death J Hospital, Institution or
Z City, Town or Village Glens Falls , Street Address 32 Goodwin Ave
pManner of Death [ Natural Cause [Accident E Homicide [Suicide l 'Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
O Terry Comeau,Coroner
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number 3�^
City, Town or Village Glens Falls,NY 5601 y
❑Burial Date Cemetery or Crematory
August 13,2018 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
ZZ n Removal } and/or Held
and/or Address
H Hold
U
o Date ( Point of
NC Transportation 1 Shipment
a by Common Destination
Carrier
I I Disinterment Date Cemetery Address
ri Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
_- Remains are Shipped, If Other than Above
2 Address
et
O. Permission is hereby granted to dispose of the human remains described above as
indicated.
Date Issued g 1 10/ zz (c Registrar of Vital Statistics L CLilly-•%. 'LA)
(signatu
District Number 5 60 1 Place 6 U^."S EAR OS 10 y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �
Date of Disposition 4 i/Stiff$ Place of Disposition i,.�\I✓ ,rg„g,itn•.../
(address)
W
CO
W (section) (lot n �,(der) (grave number)
pName of Sexton or Person in Charge of Premises (Ar•.teor .) tAil
Z j�` (please pnrrrt)
w Signature 6 Title &r I Art
(over)
DOH-1555(02/2004)