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LaVine, Gregory Charles
y � z-u 1 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Gregory Charles LaVine Male Date of Death Age If Veteran of U.S.Armed Forces, 03/12/2021 75 Years War or Dates F Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address 36 Beekman Place,Queensbury Town,New York 12804 • Manner of Death © Natural Cause ❑Accident ❑Homicide El Suicide ❑Undetermined ❑Pending U Circumstances Investigation W Medical Certifier Name Title G Wendy Steinhacker PA Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 68 ElBurial Date Cemetery,Crematory or Facility Name 03/15/2021 Pine View Crematory 0 Entombment Address 0 Cremation Queensbury Town,New York 0 Donation Removal Date Place Removed and/or and/or Held N Hold Address O Q. Date Point of U) U Transportation Ei by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Maynard D Baker Funeral Home 01130 Address 11 Lafayette St,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom F.. Remains are Shipped,If Other than Above ,2 Address W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/15/2021 Registrar of Vital Statistics Carvlrnextgarde Bader((lectronicall'Signed) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition .31 i�l7j Place of Disposition (address) W NCC (section) 1 (lot number/ (grave number) 8 Name of Sexton or Person in Charge of Pr mises / 1 in s'u 1 (pl (P/ea Print) W Signature Title at tfrv►‹: DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) J L 4 6 3 9 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#