LeBrun, Lillian Vs)CI Lncv. I I ia/ IVGW I VI I% OVUM L/GVGI IIIIWI IL VI F7G4111I
BURIAL —TRANSIT PERMIT
/Name: First Middle Last Sex
Lillian Ozilda LeBrun Female
Date of Death Age If Veteran of U.S.Armed Forces,War or Dates
E., May 20, 1980 71 No
WPlace of Death: City,Town or Village Hospital, Institution or Street Address
A City of Glens Falls, N.Y. Glens Falls Hosp.
Causes of Death:
UAcute Respiratory Failure due to Pulmonaary Edema
A Medical Certifier: Name Title Address
S. Richard Spitzer, 90 South St. , Glens Falls, NY 12801
Death Certificate Filed:City,Town or Village District No. Register No.
City of Glens Falls, N.Y.
::N)>
Date Cemeta or remato id0.1
rd�
Burial: May 24, 1980 St. Alphonsus Cemetery, Twn Queensbury, �`v1'
SS
Cremation:
Removal Date Place Removed and/or Held Address
O ❑ and/or Hold:
E-
r/ Date Point of Shipment Destination
Q Transportation by
(II ❑ Common Carrier:
r .
A Date Cemetary Address
Disinterment:
0
Reinterment:
Permit Issued To:Name of Funeral Firm Address Registration No.
Carleton Funeral Home, Inc. , Main St. , Hudson Falls, NY 00356
Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other Than Above:
E• Address:
c4 Permission is hereby granted to dispose of the dead human remains described abo as indicated
W Date Issued S --to' i�
a" Re strar of Vital Stat. t. s (Signature)
District No ,c6 0
Place
This permit must be completed on back by the person in charge at the place of disposition an d ith'the registrar of vital s atis`tics of the city,town or village
where disposition took place.
PUBLIC HEALTH LAW
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§4145. Deaths; burial and removal permits; disposition of remains.
1.No person in charge of any premises on which interments,cremations or other disposition of the body of a deceased person are made
shall inter or permit the interment or other disposition of any body unless it is accompanied Jay a burial,cremation or transit permit,as provided
in this article.
2.The funeral director or undertaker shall deliver the burial permit to the person in charge of the place of burial or other disposition,before
interring or otherwise disposing of the body;or shall attach the removal or.transit permit to the box containing the body,when shipped by any
transportation company,which permit shall accompany the remains_to its destination,where if within this state, it shall be delivered to the
person in charge of the place of burial or other disposition.
3.The person in charge of the place of burial or other disposition shall endorse upon the permit,the date of interment,or cremation or other
disposition over his signature, and shall return all permits so endorsed to the registrar of his district within seven days after the date of
interment, cremation or other disposition.
4.When burying or otherwise disposing of the body of a deceased person in a cemetery or burial place having no person in charge,the
funeral director or undertaker shall(a)sign the burial or removal permit,giving the date of burial;(b)write across the face of the permit the
words"No person in charge;"and(c)file the burial or removal permit within three days with the registrar of the district in which the cemetery is
located.
5.The person in charge of the place of burial,cremation,or other disposition shall keep a record of all bodies interred or otherwise disposed
of on the premises under his charge,in each case stating the name of each deceased person,place of death,date of burial or disposal,and
name and address of the funeral director or undertaker, which record shall at all times be open to official inspection.
ENDORSEMENT OF SECTON OR PERSON IN CHARGE OF PREMISES.
I certify that the remains were disposed of in accordance with the permit on the a reverse side on 5/24/80
(Date)
at St. Alphonsus Cemetery, Luzern Rd_ _ Glens Falls, NY
(Place of disposition and address)
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Section B-Luze me Rd. Lot No. N Grave No. 'I B
Signature Title Pastor