LaPan, Thomas NEW YORK STATE DEPARTMENT OF HEALTH /' °
Vital Records Section b - Burial - Transit Permit
Name First Middle Last 1 Sex
Thomas William LaPan Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 31 , 201 8 71 War or Dates 1 970-72
Place of Death Hospital, Institution or
LIJZ C#if,xTown or Yiitagex Moreau Street Address 22 Resevoir RD
W' IVf'anner of Death R3Natural Cause ❑ Accident ❑ Homicide E Suicide ❑ Undetermined ❑ Pending
U Circumstances Investigation
CW] Medical Certifier Name Title
3 toPPfN�' 110
Title
Address
I( O 0 cilik Cyr t I ftdo 1.
Death Certificate Filed DistriqIbLJn� Register Number
CAt,xTown oryk xx MnrPaii
❑Burial Date 4/3/18 Cemetery or Crematory Pine View Crematorium
❑Entombment Address
Tn of Queensbury, NY
O4remation
Date Place Removed
z ❑ Removal and/or Held
and/or Address
E Hold
Date Point of
a. ❑Transportation Shipment
CO-; by Common Destination
d Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
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
I— Remains are Shipped, If Other than Above
2 Address
Ce
LU
C' Permission is he eby granted to dispose of the human remain •escri f - a alive as indicated.
Date Issued _CH 03 13 Registrar of Vital Statistic /,.,,,A. NA. /�aid
(`t�� PeVo
(si'nature)
District Number D- Place 5 ( I G"fS 4iii.eaj/ / . �D-6
J
f
I certify that the remains of the decedent identified above were disposed of in accordance
�with this permit on:
W'' Date of Disposition N I'1!id Place of Disposition ?it V� (/L4o r"...,
2 (address)
W
re (section) (lot number) (grave number)
Name of Sexton or Person in Charge o Premises 1 S9..a11
(p/ ase print)
W Signature /// Title fitor-A4i in
(over)
DOH-1555 (02/2004)