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LaBarge, Keith 3l NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Keith LaBarge Male Date of Death Age If Veteran of U.S.Armed Forces, 05/03/2023 60 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address 18 Arlington Street,Glens Falls,New York 12801 111 p Manner of Death ❑X Natural Cause Accident Homicide Suicide ❑Undetermined Pending 0 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 231 Burial Date Cemetery,Crematory or Facility Name ® 05/05/2023 Pine View Crematory Entombment _ Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held I- - Hold Address 1 0 O. Date Point of d)❑Transportation Shipment p by Common Carrier Destination Date Cemetery Address Disinterment ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 2 Address IC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/04/2023 Registrar of Vital Statistics Megan.Horn(ECectronically 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: H WDate of Disposition ,j o-ZcZ3 Place of Disposition r Ale �/;eu) C { I-3 2 (address) W NCC (sedan) (lot',tiro-) (grave number) gName of Sexton or Person in Charge of miser 4JA K 0.4/_b 1 �t' Z _ (p ease print) W Signatures �" ' Title 0 I s--,c DOH-1555(07/18)p 1 of 2 1. 4 � 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#