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Newvine, Larry Duane
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records jl Name First Middle Last Sex Larry Duane Newvine Male Date of Death Age If Veteran of U.S.Armed Forces, 12/29/2020 77 Years War or Dates H Place of Death Hospital,Institution or W' City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death ©Natural Cause Accident ❑Homicide Suicide ❑Undetermined Pending C.) Circumstances Investigation LU Medical Certifier Name Title Gamal Khalifs MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 603 ❑Burial Date Cemetery,Crematory or Facility Name 12/31/2020 Pine View Crematorium 1 11 Entombment Address ElCremation Queensbury Town,New York ❑Donation • Removal Date Place Removed and/or and/or Held Hold Address 0 d Date Point of f/) 1-1 Transportation 5 by Common Shipment Carrier Destination ElDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67, Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address CC W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/30/2020 Registrar of Vital Statistics p6ertAndrew Curtis(ECectronicafy Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: � ,q • Date of Disposition /—�_;Zpa,/ Place of Disposition pi�I-� (/v e-tJ C r 2 (address W a (section) (lot number) (grave number) // Name of Sexton or Person in Charge of Premjdes R401/0r" l,d acd G7 �/ (please print) t!J Signature e y�4//// " Title O f e `II 51le DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145 - �-' Receipt Human remains of delivered on , 20 1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#