Lapolla Willaim E. -- #qt3
NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
William E.Lapolla Male
Dateof Death Age If Veteran of U.S.Armed Forces,
04/26/2020 71 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Cortlandt Town Street Address New York State Veterans Home At Montrose
`p Mannerof Death Natural Cause Accident Homicide Suicide Undetermined Pending
V Circumstances Investigation
WG Medical Certifier Name Title
Ronald Ammon MD
Address
2090 Albany Post Rd,Cortlandt Town,New York 10548
Death Certificate Filed District Number Register Number
City,Town or Village Cortlandt Town 5951 291
Burial Date Cemetery,Crematory or Facility Name
05/01/2020 Pine View Cemetery and Crematorium
Entombment Address
KCremation Queensbury,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
O
d Date Point of
W ❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
10 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Clark Funeral Home Inc 00340
Address
2104 Sawmill River Rd,Yorktown Heights,New York 10598
Name of Funeral Firm Making Disposition or to Whom
E— Remains are Shipped,If Other than Above
Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/28/2020 Registrar of Vital Statistics Garnue 2Slratzkin(ElectronicaQ Signed
(signature)
District Number 5951 Place Cortlandt Town, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H i
Z Date of Disposition S/Z.170 Place of Disposition OIL &orP.,
W
(address)
W
N
it (section) (tot number (grave number)
GName of Sexton or Person in Charge o Premises 4 - -
Z ase pr /
W Signature r-- Title �
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
3&JE,
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on bujaP p6;Qt
Official Funeral Directors Reg.or License#