Soutter, Lawrence K NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First = Middle Last Sex
Lawrence ___._.._._K Soutter male
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Date of Death Age If Veteran of U.S.Armed Forces,
September 28, 1991 76 War or Dates World War II
Z. Place of Death Hospital, Institution or
W City Town or Village City of Glens Falls Street Address Glens Falls Hospital pital
.... ........... ...........,...
Q Manner of Death.:........ _ 9
W Natural Cause Accident Homicide Suicide Undetermined Pen in
Circumstances Investigation
U ..............._:. .._ .. ..............................................
. ::. :.:: _::::.. ............
`:W' Medical Certifier Name Title
G Frederic FagelmanMD
. ....
.... ...
Address
_.454..Glen Street, Glens Falls, New York 12801
.
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Death Certificate Filed District Number Registe Jkumbor
City,Town or Village City of Glens Falls
Date Cemetery or Crematory
❑13urial Pine View Crematory
9.-30 91. ...... ,:::::... ...............:: ...... _ ... ......... _ .............
Cremation Address
Town of Queensbury, NY
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Z Date Place Removed
O Removal and/or Held
and/or Hold ......::. .
Address
.......:.:: ...............
LO1. .:....... Date Point of
cn Transportation by Shipment
pl Common Carrier .. -........ ............. ...........
Destination
Disinterment Date Cemetery Address
El El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm Regan and Denn Funeral Svc Inc _ 01602,.,,_....
.. ........ ..y .. . .... ..
Address
26 Quaker Road, Queensbury., NY 12804
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................
#-. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
... .:. .............:,.:.............. .....: .....:: :
_.:.:. .......:
att:
Address
4:1
Permission is hereby granted to dispose of the human remain escribed abo�ve as indicated.
Date Issued ( Registrar of Vital Statistics ��
(signature)
District Number —��J Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: �
W`` Date of Dispositionl �/—, / Place of Dispositions %lid/
2 (address)
W
W (section) (lot number) (grave number)
tr
pName of Sexton Person in harge of aPremis A2 /17
Z (please print)
W Signature Title �' ✓� % i
DOH-1555 (10/89) p. 1 of 2 VS-61