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LaPoint, Robert NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section >. Name First Middle Last Sex Robert E. LaPoint Sr. M .... ..... .:.::.........:.....:.:.....:.................:. .. .... ............................. Date of Death ; Age If Veteran of U.S. Armed Forces, 8/20/97 64 War or Dates no ...... ......... .. ............:..:.....,. _... z Place of Death Hospital, Institution or City,Town or Village Town of Moreau Street Address ..........:.:..........:.....::.........::::.... . :.::. D: Manner of Death .Natural Cause Accident Homicide Suicide Undetermined Pending W ® Circumstances Investigation .....::::.......::: W Medical Cert'rfier Name Title ©.... .: .:.:.. .....::.:......:.::..Aavzd.::F.00te......:.::......:.. ..:._. .:....: _.:M.D.,........:..:....:........:.:....... .:.:: .:...... .... .........-......... Address 25 George St., Fort Ann, NY Death Certificate Filed District Number Register Number City,Town or Village Town of Moreau 4562 11 Date Cemetery or Crematory ❑Burial 8/20/97 Pineview Crematorium ®Cremation Address Queensbury, NY ...:..:.. .. :..:::... ....... Z Date Place Removed 0! [] Removal and/or Held and/or Hold :....... ...:..::. :..... :. .:..... .:.- ... .,:.::::.. :::... :::..:. . ... .... Fn Address 0 .:. ...:: :.:: _ . ....... ......... .......: .:. .. .. a Date � Point of tn' Transportation by Shipment p Common Carrier ..., : ...... _::... ....:::..:..:.:. .__ ........_:...:... Destination ................... ..:. _:::...................: .. ............................................. ..... ........_ _ Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Firm Mason Funeral Home _.:.:..... Q1.21f�:.::..... _.......: .:::::.: Address 63 George St., Fort Ann, NY 12827 ..:...... ....:...:.:......:::. . ....... ...... ......................- _: :. t- Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above .t .. .. .. ....................... Address U1'r a .:.: ........ ... ..:::.:: ............................ ... ........ Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 8/20/97 Registrar of Vital Statistics (sic ture) District Number 4562 Place 61 Hudson Street, South Glens Falls, NY 12803 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: w Date of Disposition�7 Place of Disposition �// '111= � ( .�� � (address) ,w` U) (section) (lot num } (grave number) a p Name of Sexton Ar Person iiNharge of Preplises Zj (,please pant) W Signature Tiile(� �/G7/C��✓J l /' VS 61 DOH-1555 (10/89) p. 1 of 2