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LaGoy, Edward A NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Edward A.LaGoy Male Date of Death Age If Veteran of U.S.Armed Forces, 01/26/2022 79 Years War or Dates F— Place of Death Hospital,Institution or Z City,Town or Village Bolton Town Street Address 24 Potter Hill Road,Bolton Town, New York 12814 111 p Manner of Death © Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title CI Mary Stein NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Bolton Landing 5650 1 ❑Burial Date Cemetery,Crematory or Facility Name 01/27/2022 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York ❑Donation Z El Removal Date Place Removed and/or and/or Held F Hold Address 0 Q. Date Point of d) ❑Transportation 5 by Common Shipment Carrier Destination Date Cemetery Address ❑Disinterment Date Cemetery Address El Reinterment Permit Issued to Registration Number Name of Funeral Home Alexander Baker Funeral Home 00037 Address 3809 Main St,Warrensburg,New York 12885 Name of Funeral Firm Making Disposition or to Whom 1— 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 01/27/2022 Registrar of Vital Statistics Jodi Petteys(Electronically Signed) (signature) District Number 5650 Place Bolton Landing, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 9 Z Date of Disposition I/271?2 Place of Disposition '1 'a c &_. W (address) W CC (section) (lot number) (grave number) Name of Sexton or Person in Charge o Premises 101 t Se ti t It Z (Pease print) W Titlel('A-``i Signature DOH-1555(07/18)p 1 of 2 I • 1592 Public Health Law Sec. 4145(2b) 1 Receipt 1 Human remains of delivered on , 20 1 ii Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# ` '