LaValley, Paul • f
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Paul Andrew LaValley Male
Date of Death Age If Veteran of U.S. Armed Forces,
I- June 21. 2006 72 War or Dates
2 Place of Death Hospital, Institution or
W City, Town, or Village Glens Falls Street AddressGlens Falls Hospital
G Manner of Death x❑ Natural Cause ❑ Accident ❑ Homicide El Suicide ❑ Undetermined n Pending
W Circumstances Investigation
( Medical Certifier Name Title
W FRED P SCIALABBA MD
0 Address
454 Glen St., Glens Falls, NY 12801
+ Death Certificate Filed District Number Register Number
1 City, Town or Village Glens Falls 5 / a73
Date Cemetery or Crematory
❑ Burial June 26, 2006 Pine View Crematorium
Address
E1 Cremation Ouaker Road Oueensburv, NY 12804-
Date Place Removed
0 ❑ Removal and/or Held
- and/or Address
Hold
0 Date Point of
0 ❑Transportation _ Shipment
d by Common Destination
0 Carrier
Date Cemetery Address
0 ❑ Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00284
Address
F- 68 Main St., P. O. Box 67, Hudson Falls, New York 12839
Name of Funeral Firm Making Disposition or to Whom
a Remains are Shipped, If Other than Above
w Address
0.
Permission is here y granted to dispose of the human remains described�ee,ndi d
Date Issued i06. 2-3 iiiC Registrar of Vital Statistics
(signature)
District Number ,5%Q/ Place Glens Falls,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 4-24 -,:,4. Place of Disposition Pi illr i I 1 to) C cz El.A-im-E0 v'- C 4
w (address)
44
IX (section) (lot number) (grave number)
0
Z Name of Sexton or Person in Charge of Premises 5- �' 6-a' Ai ,7
(please print) I
Signature_, 6 y-C(��, Title ��/.Z ' '}fO f�
G