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NEW YORK STATE DEPARTMENT OF HEALTH It I Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Paul A.LaFond Male
Date of Death 1 Age If Veteran of U.S.Armed Forces,
12/02/2020 75 Years War or Dates Vietnam
1— Place of Death Hospital,Institution or
WCity,Town or Village Lake George Town Street Address 2858 State Route 9,Lake George Town,New York 12845
p Manner of Death ❑X Natural Cause 0 Accident I=1 Homicide Suicide 0 Undetermined 0 Pending
W 0Circumstances Investigation
W Medical Certifier Name Title
O Connie Goedert Coroner
Address
1400 St Route 9,Lake George Town,New York 12845
Death Certificate Filed District Number Register Number
City,Town or Village Lake George 5651 7
❑Burial Date Cemetery,Crematory or.-€adility Name
12/07/2020 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,Ne>York
❑Donation -
"Z Removal Date Place Removed
d and/or and/or Held
I—
Hold Address
0
Date Point of
Cl) ❑Transportation Shipment
Q by Common
Carrier Destination
Date Cemetery Address
0 Disinterment
Date Cemetery Address
❑Reinterment
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
g Address
CC
ILLI
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/07/2020 Registrar of Vital Statistics 'atncra 4 �fc"KinneYSc1urter(Ekctronicali:y Signe,
(signature)
District Number 5651 Place Lake George, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
4
111 Date of Disposition fikhb Place of Disposition (ddres�
W
Ch
CC (section)
lot number) (grave number)
O Name of Sexton or Person in Cha a of Premises r(gi' `��`
O (pleas print)
W Signature �C//�.-- Title '" nit
g
DOH-1555(07/18)p 1 of 2
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Public Health Law Sec. 4145(2b) 01,1
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#