LaCross, Paul Anthony L di 3
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Paul Anthony LaCross Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/08/2022 74 Years War or Dates
�.. Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
p▪ Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
O Scott Biasetti MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 24
❑Burial Date Cemetery,Crematory or Facility Name
01/11/2022 Pine View Crematorium
❑Entombment Address
X❑Cremation Queensbury Town,New York
▪Donation
g ❑Removal Date Place Removed
and/or and/or Held
Hold Address
CO
Date Point of
M ❑Transportation
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
t Remains are Shipped,If Other than Above
2 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/10/2022 Registrar of Vital Statistics Megan Nolin(ECectronicaCCySigned)
(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:
H
Z Date of Disposition I`1217z Place of Disposition
lw address)
W
CO (section) (tot number) (grave number)
8 Name of Sexton or Person in Charge of Premises �t,' �'-- tt
(p/e a print)
W Signature I/ Title 5 100%`1.
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#