Lapier, Jeffrey J . 4/ (so
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jeffrey J LaPier Male
Date of Death Age If Veteran of U.S.Aed Forces,
06/12/2022 48 Years War or Dates-,.
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W W Manner of Death Natural Cause Accident Homicide nSuicide Undetermined Pending
U Circumstances Investigation
W Medical Certifier Name Title
0 Timothy Murphy Coroner
Address
52 Haviland Avenue,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 315
EBurial Date Cemetery,Crematory or Facility Name
06/14/2022 Pineview Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
a. Date Point of
N❑Transportation
Cl Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Date Cemetery Address
❑Reinterment
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
F— Remains are Shipped,If Other than Above
a Address
Q
NU
0-
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/14/2022 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ZIJJ Date of Disposition W ?Z 1ISi Place of Disposition ,�
(address)
W
Cl)°G in Charge of Premises i
(section) A(lot number) S4tf
(grave number)
g Name of Sexton or Person ..
��
2L (pleas rint) G
W tx
Signature Title �` �
DOH-1555(07/18)p 1 of 2
15786
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#