LaCross, LeRoy Louis Jr. NEW YORK STATE DEPARTMENT OF H EALTH LF I
Bureau of Vital Records burial - Transit Permit
Name First Middle Last Sex
LeRoy Louis LaCross Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/04/2023 69 Years War or Dates
i_ Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
111
p Manner of Death ❑X Natural Cause Accident []Homicide []Suicide []Undetermined ❑Pending
0 I (Circumstances Investigation
W Medical Certifier Name Title
CI Melody Long PA .
Address
100 Park Street,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 64
[]Burial Date Cemetery,Crematory or Facility Name
02/06/2023 Pine View Crematory
Entombment Address
EX Cremation Qu'eittsbury Town,New York
Donation
Z Removal Date Place Removed
and/or and/or Held
H Hold Address
N
O
O Date Point of
N OTransportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
El Reinterment
Permit Issued to 4 Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
N Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/06/2023 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:
I— 1
Z Date of Disposition Z j) I Z 3 Place of Disposition ,.,Q ,;ti,rs
LU (address)
W
N (section) (lot numbe (grave number)
u
O• Name of Sexton or Person in Charge of P ' es C M\1� l
( ease print)
Z
Title F e
W Signature �,mW�
DOH-1555(07/18)p 1 of 2
c,, ]]
f °" ` 'jp 9 t't
Public Health Law Sec. 4145(2b)
Receipt
1
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#