Bigelow, Lawrence NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
............. L.awr.enc.e.:...:.:Guy .,.: :.0. :g.e1.Qw. ... :..: M:ale
Date of Death Age If Veteran of U.S.Armed Forces,
. 19.9.0.. 4.4. War or Dates..
Place of Death Hospital, Institution or
ii{ City,Town or Village ... C�..t,y of.....Ga e n s,.. F a ll$Street Address G 1 e n.s....E.:a.1.1.s::..H.o.:s. it.a.l
C Manner of Death Undetermined Pending
W Natural Cause ❑ Accident ElHomicide ❑ Suicide ❑ ri vess
Circumstances Investigation
lV Medical Certifier Name Title
C
Vincent D . Koh , MD
al Address
4:28 ..G.l.en..:.St.. ,:...G.1e.ns.....F:a.l.l.s IVY_:::::.1.2.0.0.:1 ........ .:.... .......:: .. ...... .......::: ... ...
iNi Death Certificate Filed District Number Register Number
City,Town or Village City Glens Falls 5601 7/R.7
Date Cemetery or Crematory
XEI Burial Dec . 29 , 1990 Pine View Cemetery
El Cremation Address
Town of Queensbury , NY
Z Date Place Removed
0 ❑ Removal and/or Held
ii— and/or Hold :.:.... .:::.
Address
co
................. ........: ........... ........ .......:...... .. ........ ..............- ........ ........ .
a Date Point of
cn• ❑Transportation by Shipment
pl Common Carrier ....... ...:::.:.
Destination
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm C a r l,e t o n.,:......... Home ., Inc ,......_:::: 00310 .,,,.:....
Address
§i.ii',1 Hudson Falls , NY 12839
#-: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
it Address
la
Permission is hereby granted to dispose of the human re ins describe above as indicated.
Date Issued A-2 ` DL ; G�
� Registrar of Vital Statistics (signature) / /
District Number `J 7) 0 / Place _)e-eiv��_z__:y '.'`J / 4` / �0 f
J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i-
W' Date of Disposition /•2'-2 f - 'C' Place of Disposition fa/,,�:` ez i=u L'�`! -. ' -x-,jJ C a t�G=_,sr4 4'":�✓� :L, y
(address)
w O N/c a.il f,_• - �- /
N:>r (section) (lot number) (grave number)
O 7
p' Name of Sextonpr-Person in Charge of Premises P 0 ''._ Cy - . v a h/j=��
Z- / (please print) S
- Signature (_) -ate -<;L'ti�. cti--c `� Title L.- cri
DOH-1555 (10/89) p. 1 of 2 VS-61