LaBrake, James l "Orly
NEW YORK STATE DEPARTMENT OF HEALTHir 11' if
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James Howard LaBrake Male
Date of Death Age if Veteran of U.S. Armed Forces,
V 12/12/2018 69 Years War or Dates 1969-1970
' Place of Death
i
Hospital, Institution or
City, Town or Village Granville Town
StreetAddress Suicide
echard Nursing And Rehabilitation Centre
j
Manner of Death nre DHomicide o ci
ib Natural Cause Ej Accidentn Undetermined n Pending
1 Medical Certifier Name Title
Leonard Gelman MD 1-1 Circumstances 'Investigation
41 Address
, - 10421 State Route 40,Granville Town,New York 12832
A Death Certificate Filed District Number Register Number
City,Town or Village Granville 5756 67
-:*0 Burial Date Cemetery or Crematory
12/13/2018 Pine View Crematorium
0 Entombment Address
tALiairemation Queensbury Town, New ark
k' Date Place Removed
AN*ri Removal and/or Held
igi"""*J and/or Address
' Hold
/-
Date Point of
rDi Transportation Shipment
7:1I by Common Destination
-,. Carrier
Disinterment,
Date Cemetery Address
0
Et Reinterment Date Cemetery Address
.2.:;
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
'.& Address
fl 68 Main Stpo Box 67,Hudson Falls,New York 12839
' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
--21 Address
, Permission is hereby granted to dispose of the human remains described above as Indicated.
; -
,., Date issued 12/13/2018 Registrar of Vital Statistics jenny Linda alarteiD(E&ctronicarry Signed)
4.TE
(signature)
District Number 5756 Place Granville, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 1011 lit Place of Disposition -1,74,./ ino-c-tof-v
a (address)
tU
0
a (section) 4. (lot number) (--- (grave number)
0 Name of Sexton or Person in Charge pf Premises (h prholi r ......)e-wir
A (please print)
Signature ../I 1(44 Title ittfrvta
(over)
DOH-1555 (02/2004)
a