LaPan,Tory E . ., 4 (11 ZZr,
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Tory E. LaPan Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/18/2022 42 Years War or Dates
1.,„ Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
O Manner of Death El Natural Cause Accident Homicide nSuicide Undetermined ❑Pending
LLI
U Circumstances Investigation
ra Medical Certifier Name Title
Q Timothy Murphy Coroner
iii
Address
52 Haviland Avenue,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls istrict Number Register Number
City,Town or Village 5601 279
Burial Date Cemetery,Crematory or Facility Name
05/23/2022 Pine View Nary
Entombment— Address
IICremation Queensbury Town,New York
❑Donation
oz
❑Removal Date Place Removed
and/or and/or Held
t Hold Address
iiiiNit
0
CL Date Point of
0❑Transportation
G by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home Inc 00211
Address
24 Church Street PO Box 500,Lake Luzerne,New York 12846
Name of Funeral Firm Making Disposition or to Whom
F.. Remains are Shipped,If Other than Above
1 Address
LIE
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/23/2022 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition Shy- 2Z Place of Disposition }.�� �;
IF—
/address)
W
a (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premiss hi 4 L . SPN if
/p ase print/
US
Signature Title ammigbe
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#