Perna, Lawrence / ( IS: ‘1 GI
NEW YORK STATE DEPARTMENT OF HEALTH "'"" Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Lawrence Perna Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/16/2022 59 Years War or Dates
i_ Place of Death Hospital,Institution or
WCity,Town or Village Stony Creek Town Street Address 8 Harrisburg Road,Stony Creek Town, New York 12878
pManner of Death ❑X Natural Cause Accident Homicide Suicide ❑Undetermined Pending
U Circumstances Investigation
W Medical Certifier Name Title
O Lynn Keil PA
Address
1340 State Route 9,Lake George Town,New York 12845
Death Certificate Filed Town Of Stony Creek District Number Register Number
City,Town or Village 5658 6
Burial Date Cemetery,Crematory or Facility Name
11/19/2022 Pine View Crematory
Entombment Address
EICremation Queensbury Town,New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
d Date Point of
U)OTransportation Shipment
Q by Common
Carrier Destination
D
Disinterment
Date Cemetery Address
EIReinterment Date Cemetery Address
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
-. Remains are Shipped,If Other than Above
5 Address
Q
W
0. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/18/2022 Registrar of Vital Statistics Susan I7farrington(ECectronicallySigned)
(signature)
District Number 5658 Place Town Of Stony Creek
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W~ \ . /J�d
Date of Disposition l i 12�11L Place of Disposition �� Y r�
2 (address)
uJ
NCC (section) 4 „number) (grave number)
8 Name of Sexton or Person in Charge of Premises f'4v_, s"p,ri-
z (pse print/
W Signaturez. Title �12L n1 "�
DOH-1555(o7/t8)p t of 2
1. 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#