Lomax, James tiq`i•
NEW YORK STATE DEPARTMENTOF HEALTH
Vital Records Section R_ Burial - Transit Permit
Name First Middle 'N Last Sex
James A. Lomax Male
Date of Death Age If Veteran of U.S.Armed Forces,
October 9,2006 82 War or Dates World War II
Place of Death City of Glens Falls Hospital, Institution or Glens Falls Hospital
z City,Town or Village Street Address
III Manner of Death Q Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
G Circumstances Investigation
�Wj Medical Certifier Name Title
W Suzanne M.Rayeski Physician
Address
3767 Main St.,Warrensburg,NY
Death Certificate Filed District Number Register Number
City,Town or Village City of Glens Falls 5601 79X
El Burial Date Cemetery or Crematory
10/10/2006 Pine View Crematory
❑ Entombment Address
tEl Cremation Queensbury,NY
Date Place Removed
z ❑ Removal and/or Held
Q and/or
r Address
N Date Point of
a ❑ Transportation Shipment
(1).z... by Common Destination
Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Renterment
Permit Issued to Registration Number
Name of Funeral Home Alexander Funeral Home,Inc. 00037
Address
4479 State Route 28,North River,NY 12856
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped, If Other than Above
- Address
eg
dPermission is hereby granted to dispose of the human mains cribed bove as in. . ...
Date Issued 10/10/06 Registrar of Vital Statistics Zr1V.,,-1-y
signature)
District Number 5601 Place City of Glens Falls,City Hall,Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1— ,
Z Date of Disposition 1 c/w/C , Place of Disposition i n t,,i d J (re.,c-i v r
ILI (address)
W
d) (section) c(lot number) (grave number)
CZ
0 Name of Sexton or Person in Charge of Premises C b �.v,4
�`°�
Z /� F (please print)
W Signature (_ Title ^\fL,C
DOH-1555(02/2004) (over)