LaFountain,William J Jr. ,
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
William J LaFountain Jr Male
Date of Death Age If Veteran of US.Armed Forces,
01/18/2023 93 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Albany Street Address St Peters Hospital
III
p -Manner of Death II Natural Cause ❑Accident Eil Homicide Suicide Undetermined riPending
W
C.) Circumstances Investigation
W Medical Certifier Name Title
0 Dan Liu MD
Address
315 S Manning Blvd,Albany,New York 12208
Death Certificate Filed City Of Albany r District Number Register Number
City,Town or Village 0101 0137
Burial Date Cemetery,Crematory or Facility Name
® 01/20/2023 Pineview Crematory
Entombment Address
Cremation Queensbury Town,New York
DDonation
Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
d Date Point of
W❑Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
Reinterment Date Cemetery Address
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
10— Remains are Shipped,If Other than Above
SAddress
Q
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/19/2023 Registrar of Vital Statistics Danielle S Gillespie(Electronically Signed)
(signature)
District Number 0101 Place City of Albany
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition i 120 1 Z3 Place of Disposition ' , IL / `"---"--
W /address)
W
N (section) (lot number) (grave number)
Sa0 "(;1eat)
Name of Sexton or Person in Chargeremi s
Z r
Ili - Title ` n
DOH-1555(07/18)p 1 of 2
1 I
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#