Lux, Mary Lee NEW YORK STATE DEPARTMENT OF HEALTH q t1
Vital Records Section - Burial - Transit Permit
Name First Middle Last Sex
Marylee j i uY
Female
Date of Death Age If Veteran of U.S. Armed Forces,
05/01/2006 71 years War or Dates
}- Place of Death Hospital, Institution or
LLICity, Town 4X�(R4g16XXXX City Of Glens Falls Street Address Glans Fails Hospital.
• Manner of Death g Natural Cause ❑Accident ❑Homicide ❑Suicide El❑ Undetermined El❑Pending
ILI Circumstances Investigation
iii Medical Certifier Name Title
CI Sean Bain M n
Address
Glens Falls Hospital, Glens Falls, N Y
Death Certificate Filed District Number Register Number
City, Town el9QgfigivXXXX City Of Glens Falls 5601 1 gfl
❑Burial Date Cemetery or Crematory
05/05/2006 Pine View Crematorium
❑ rtitombment Address
Cremation Queensbury, NY 12804
Date Place Removed
Z❑Removal and/or Held
2 and/or Address
M=
U) Hold
Date Point of
Cti
❑Transportation Shipment
O by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Robert M. King Funeral Home 01573
AddressLhurch Street Granville, NY 12832
Name of Funeral Firm Making Disposition or to Whom
- Remains are Shipped, If Other than Above
Address
tr
ILI
P` Permission is hereby granted to dispose of the human remains described above a - dic
0510312008 �I �
Date Issued Registrar of Vital Statistics fL a
(signature)
District Number)9 j Place 6 (,Qiv _ , \S ! )y
1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1u Date of Disposition 5 /(o/D b Place of Disposition R,iP v",,,: Cf lt,,,,,, rut,,j,...
i (address)
W
U)
CC (section) (lot number) (grave number)
• Name of Sexton or Person in Charge of Premises (,),r,. e't,t R/'
2 (please print)
Signature C111
Title Ci I m c. I
(over)
DOH-1555 (02/2004)