Lyons, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH I 1
Vital Records Section Burial - Transit ermit
Name First Middle Last Sex
Dorothy E. Lyons Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 1, 2013 88 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address The Orchard Nursing & Rehabilitation Cent
Manner of Death El Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Address Qp il`,
Death C rtificate Filed District Number Register Number
City owrpor Village "RA'$ I L>r 5'7S4, e
0 Burial Date Cemetery or Crematory
March 6, 2013 Pine View Crematory
❑Entombment Address
l®Cremation uuaKer Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held Pine View Crematory
and/or Address
Hold Quaker Road Queensbury,NY 12804
Date Point of
Transportation Shipment
It by Common Destination
ta Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
.p❑ Reinterment
Z
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
2, Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 0 3/0 411a013 Registrar of Vital Statistics IW
(s?:itid.e/
ature)
District Number Silt, Place 701An1 D r 6 RAN tlit.i &
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
vl Date of Disposition 03/06/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) /I (lot number). (grave number)
Name of Sexton or Person in Charge of remises t AtlieKall+
(please print)
� Signature Title c.t.lf&me.
(over)
DOH-1555 (02/2004)