LaCross, Michael ti89$
NEW YORK STATE DEPARTMENT OF HEALTH _ • %.,Vital Records Section Burial - Transit Permit
,
Name First Middle Last Sex
Michael Robert LaCross Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 30, 2018 66 War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Fort Ann Street Address 1641 Mattison Road
WW Manner of Death Ei Natural Cause El Accident Homicide D Suicide riUndetermined ri❑ Pending
Circumstances Investigation
W' Medical Certifier Name Title
Cr Dr. Donald Merrihew,
Address
Convenient Medical Care Queensbury, NY 12804
Death Certificate Filed District Number Register Number
T City, Town or Village 5 r) 5LI ) 1
0 Burial Date Cemetery or Crematory
November 5, 2018 Pine Vew Crematorium
❑Entombment Address
®Cremation Queensbury,NY 12804
Date Place Removed
46.71 Removal and/or Held
and/or Address
Hold
CO Date Point of
eL ❑Transportation Shipment
Co by Common Destination
a Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
l- Remains are Shipped, If Other than Above
• Address
CC
W.'
Permission is hereby granted to dispose of the human remains described above as Indic�j ted.
Date Issued i/ c i Registrar of Vital Statistics . (X) ,�p
(signature)
I District Number 5 i5 Place 1p w n of r c-)( - An ✓1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
in• Date of Disposition 11/05/2018 Place of Disposition Queensbury,NY 12804
(address).
a,
(1)-
it (section) lot number) S (grave number)
O Name of Sexton or Person in Charge of Premises fr» v +A^,If
z
(please print)
W Signature �✓ • - Title jvliA1i _
(over)
DOH-1555 (02/2004)