LaRocque, Cheryl Dianne r /.\ ,F).. qc
NEW YORK STATE DEPARTMENT OF HEALTH — Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Cheryl Dianne LaRocque Female
Date of Death Age If Veteran of U.S.Armed Forces,
07/15/2022 74 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Kingsbury Town Street Address 438 County Route 41 Street,Kingsbury Town,New York 12839
0 Manner of Death II Natural Cause Accident Homicide Suicide []Undetermined ❑Pending
O ` 'Circumstances Investigation
W Medical Certifier Name Title
0 Darci Gaiotti-Grubbs MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Kingsbury District Number Register Number
City,Town or Village 5762 15
Burial Date Cemetery,Crematory or Facility Name
07/19/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
O
Date Point of
(I) Transportation
by Common Shipment
Carrier Destination
El
Disinterment
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
H Remains are Shipped,If Other than Above
a Address
CC
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/19/2022 Registrar of Vital Statistics Cynthia Barden(ECectronically Signed)
(signature)
District Number 5762 Place Town Of Kingsbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition "� f Zv/11. Place of Disposition 'FAL�/�
W
(address)
W
CC (section) (lot number) s:ii (grave number)
SName of Sexton or Person in Cho Premises ^• 4
Z ase print)
W Signature Title 111
DOH-1555(018)p t of 2
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#