Ladd Sr, William NEW YORK STATE DEPARTMENT OF HEALTH , h
Vital Records Section Burial - Transit Permit
•
Name First Middle Last Sex
William George Ladd Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
09/09/2011 73 years War or Dates
14. Place of ueath Hospital, Institution or
Z City, To Street Address
III �� Glens Falls Glens Falls Hospital
Manner o eat ❑f�latural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
iii Medical Certifier Name Title
Dean A Reali M D
Address
3767 Main Street Warrensburg, N Y 12885
HI Death Certificate Filed District Number Register Number
City, TovieyeAxViyatxx nle,s Fallc 5601 403
❑Burial Date Cemetery or Crematory
❑Entombment 09/13/2011 Pine View Crematorium
Address
❑ciemation Oueenshury, NY 12804
Date Place Removed
Z Removal and/or Held
2L—I and/or Address
N Hold
® Date Point of
N ❑Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment ,Date Cemetery Address
❑Reinterment 'I Date Cemetery Address
Permit Issued to - Registration Number
Name of Funeral Home Brewer Funeral Home, Inc. 00211
Address
24 Church Street Lake Luzerne, N Y 12846
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address .
tr
.111
7. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/12/2011 Registrar of Vital Statistics W c.AA4 .� k
(signature)
District Number Place
5601 Glens Falls
"`' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition ' Q((({(It Place of Disposition „u U*ev C0,4•i i
2 (address)
la
to
i (section) (lot nur) (grave number)
Name of Sexton or P son in Char of Premises I►r isAiriLl r Je.144
(please print)
Si nature Title CQ 4i
g - End
(over)
DOH-1555 (02/2004)