LaPan, Mary NEW YORK STATE DEPARTMENT OF HEALTHY t 1 Burial
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Vital Records Section - Transit Permit
I Name First Middle Last Sex
Mary A. LaPan Female
I Date of Death Age If Veteran of U.S. Armed Forces,
August 26, 2016 80 ` War or Dates
1 '• c2c= of Death Hospital, Institution or
LU City own or Village Glens Falls - Street Address The Pines
0 anner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
C)
LU Medical Certifier Name Title
CI Mellissa Dedrea, M.D Dr.
Address
9 Carey Road Queensbury, NY 12804
h Certificate Filed District Number Register Number
City own or Village l e n S 'Fa l S 5601 93Y
Burial Date Cemetery or Crematory
August 29, 2016 Pine View Crematorium
0 Entombment Address
!Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
7 El Removal and/or Held
and/or Address
F. Hold
01 Date Point of
I I Transportation Shipment
co by Common Destination
t3 Carrier
Date Cemetery Address
I I Disinterment
0 Reinterment I Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
2, Address
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'', Permission is hereby granted to dispose of the human remains describ dabb ve s ii ed.
Date Issued D$ w/G Registrar of Vital Statistics ,1, �
(signature)_
District Number 5601 Place m4 13, /V?-)
t— I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W; Date of Disposition 08/29/2016 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
w
co
c (section) (lot number) (grave number)
0 4.—
Name of Sexton or Person in Charge of Premises ,5,�4(
2 a (please print)
Signature Title C }fut.
(over)
DOH-1555 (02/2004)