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LaRosa, Anthony S
NEW YORK STATE DEPARTMENT OF HEALTH �I�� Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Anthony S.LaRosa Male Date of Death Age If Veteran of U.S.Armed Forces, 05/20/2023 76 Years War or Dates I_ Place of Death Hospital,Institution or Z City,Town or Village Johnsburg Town Street Address Elderwood at North Creek UJ p Manner of Death 0 Natural Cause ❑Accident n Homicide Suicide Undetermined Pending QW Circumstances Investigation Medical Certifier Name Title Leah Terry NP Address 4573 State Route 40,Argyle Town,New York 12809 Death Certificate Filed Town Of Johnsburg District Number Register Number City,Town or Village 5655 18 Burial Date Cemetery,Crematory or Facility Name mu= 05/24/2023 Pine View Crematory Entombment _ Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held N Hold Address 0 O. Date Point of f)Dransportation p by Common Shipment Carrier Destination ODisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Maynard D Baker Funeral Home 01130 Address 11 Lafayette St,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above a Address CC N,I a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/24/2023 Registrar of Vital Statistics jean ti ComstockfE(ectronica((y Signed) (signature/ District Number 5655 Place Town Of Johnsburg I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— Z Date of Disposition 5 in 1 I Place of Disposition .1:kL 4--. 11.1 2 (address) W CC (section) (lot number) (grave number) SName of Sexton or Person in Charge of remises dr. +. !►t Z (lL— v� ease print) W Signature Title !' ►ijvr2 DOH-1555(o7/18)p 1 of 2 Public Health Law Sec. 4145(2b) ll I Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#