Lanza, Nicholas Frank Jr. Ilivs.:!)NEW YORKSTATE DEPARTMENT OF HEALTHBurial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Nicholas Frank Lanza Jr Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/26/2022 54 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Moreau Town Street Address 8 Jacobie Road,Moreau Town;New York 12803
IJJ
Q Manner of Death Natural Cause []Accident []Homicide Suicide FlUndetermined Pending
ILI
Circumstances "—Investigation
W Medical Certifier I Name Title
0 Eugene Ladue Coroner
kddress
6012 County Farm Road 11 ,Ballston Town.New York 12020
Death Certificate Filed Town Of Moreau District Number Register Number
City,Town or Village 4562 14
[ ]Burial Date I Cemetery,Crematory or Facility Name
03/3112022 I Pine View Crematorium
[]Entombment Address
[]Cremation Queensbury Town,New York
Donation
Date Place Removed
0[]Removal and/or Held
1- and/or
N
Hold Address
0
Date Point of
Cl)ETransportation Shipment
p by Common
Carrier Destination
[]Disinterment Date Cemetery Address
Date Cemetery Address
Reinterment
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
F— Remains are Shipped,If Other than Above
Address
Q
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/30/2022 Registrar of Vital Statistics Leeann`i1c cafe(Electronica!/v,S`igned/
(signature)
District Number 4562 Place Town Of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 1 II I 22- Place of Disposition 171,41....-
r._.
2 ddress)
W
Cl)CC (section) /J(lot number) �►�' (grave number)
O Name of Sexton or Person in Charge of Pr ' es r!4
(plea print)
z (rein u4
MI Th
Title
DOH-1555(07/18)p 1 of 2
T.
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#