White, Wallace Vane # `1310
(LF,
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Wallace Vane White Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/26/2022 62 Years War or Dates 1982-1984
Place of Death Hospital,Institution or
W City,Town or Village Hudson Falls Village Street Address 32 Maple Street, Hudson Falls Village, New York 12839
p Manner of Death El Natural Cause Accident El Homicide 0Suicide 71Undetermined nPending
W Circumstances / ''Investigation
U
W Medical Certifier Name Title
Robert Lemieux Coroner
Address
415 Lower Main Street,Hudson Falls Village,New York 12839
Death Certificate Filed Village Of Hudson Falls District Number Register Number
City,Town or Village 5726 46
nBurial Date Cemetery,Crematory or Facility Name
11/29/2022 Pine View Crematorium
nEntombment Address
Cremation Queensbury Town,New York •
IliDonation
ZO❑Removal Date Place Removed
and/or and/or Held •
H Hold Address
0
n. Date Point of
(I)❑Transportation Shipme,it
by Common
Carrier Destination
Date Cemetery Address
nDisinterment
Date Cemetery Address
E 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
Remains are Shipped,If Other than Above
5 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/29/2022 Registrar of Vital Statistics Cynthia (Bardin(ECectronicalTy Signed)
(signature)
District Number 5726 Place Village Of Hudson Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-
WDate of Disposition I? ► I ZZ Place of Disposition
2 laddres)
W
N (section) 3 (lot number) (grave number)
Q
Name of Sexton or Person in Charge e ices ''` �
Z ( ease print)
W Signature Title ` ¢�m44
DOH-1555(07/18)p 1 of 2
1..64 4.4
Public Health Law Sec. 4145(2b) ..
Receipt
Human remains ofw delivered on , 20
Pine View Cemetery Representing the funeral home named;on,buuial permit
Official Funeral Directors Reg.or License#