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LaPan, Phyllis Ann
3 g,, NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Phyllis Ann LaPan Female Date of Death Age If Veteran of U.S.Armed Forces, 04/28/2021 86 Years War or Dates F Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital WManner of Death ©Natural Cause 0 Accident 0 Homicide Suicide 0 Undetermined 0 Pending Circumstances Investigation WL Medical Certifier Name Title Laurie Dennison NP Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 197 ❑Burial Date Cemetery,Crematory or Facility Name 05/31/2021 Pine View Crematorium 0 Entombment Address X❑Cremation Queensbury Town,New York ❑Donation ZRemoval Date Place Removed and/or and/or Held N Hold Address 0 tai) Li Transportation Date Point of p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67, Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom - Remains are Shipped,If Other than Above 2 Address CC W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/01/2021 Registrar of Vital Statistics Yg6ertAndrew Curtis(ECectronicaffy Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition S 131 11 Place of Disposition i� p (address) W CC (section) (/ number) (grave number) CC 0 Name of Sexton or Person in Charge of Pr ises (pleasepri r)� Signature Title (Vj ""N DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) ,�{ l 5 4 Receipt Human remains of delivered on , 20 s Pine View Cemetery Rep presenting the funeral home named on burial permit Official Funeral Directors Reg.or License#