La Pan, Walter NEW YORK STATE OEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rze This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registered No.
Town, Village
Dist. No. 5601 County Warren or City...Glens...Falls l-los.pital
(If city, give street address)
Name of deceased Walter D La!an Veteran yes WW II
(If veteran, give name of War)
Male Single, married, widowed, Dec. I1
Sex or divorced (write the word) MarriedDate of Death 19 70
Age 46 Years 10 Months 11 Days Birthplace Glens Fa :.l.s....N..Y.
Cause of Death Cardiogenic Shock
Certificate was signed by Sigmund Weiss M.D.
Address 6 Elm Street Hudson Falls N.Y. 12839
Place of Burial (or Removal) Twn Queensbury Warren Co.N.Y.
(If body is to he temporarily he d, fill in space later)
Cemetery Pineviewl Date of Burial ....D.ec...14 19 ...70...
(If body is to he temporarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,the
same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra•
tion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT
tcarleton Funeral Home Inc. (A.C.Wilson) Hudson Falls N.Y.
(Name) (Address)
the Funeral Director to hold temporarily and ... Inter the body
(Undertaker or personl having charge of corpse) (Inte remove, otiptherwi o di f (state how))
Dated Dec. 19
or (Signed) 1 ..L // i I/i~'
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to anfr part of the• LocalRegistrar
a (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required. _"-'"
FORM VS. 61. (REV. 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date was 19 70
(Interment or C
•
(Name of Ceme�e , ou..)
� G
Section No. 17 �Grave No. 6
Si e �
(Persn in Charge)
Address
F e n in charge must return this Permit to the Regi fr r
of his District within SEVEN (7) DAYS from above date. If no
person is in charge, the FUNERAL DIRECTOR or UNDER-
TAKER MUST SIGN ABOVE STATEMENT, write across the
face of the Permit the words "No person in charge," and
FILE PERMIT WITHIN THREE (3) DAYS with the Registrar
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return of permits are liable to
a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE
THAN FIFTY DOLLARS !OR THE FIRST OFFENSE. The
law will be enforced. Loral Registrars are required, under
penalty, to report violations thereof.