Lyons, Mary NEW YORK STATE DEPARTMENT OF HEALTH RI)- 1
Vital Records Section 1 ! Burial - Transit Permit
Name First Middle Last Sex
Mary Elizabeth Lyons Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 20, 2012 95 War or Dates
F--, Place of Death Hospital, Institution or
W. City, Town or Village Fort Edward Street Address Fort Hudson Nursing Center, Inc.
0 Manner of Death 0 Natural Cause Eli Accident ❑Homicide 0 Suicide El UndeterminedEl Pending
U' Circumstances Investigation
W± Medical Certifier Name Title
CV, Thomas F Kandora, M.D
Address
7240 Upper Broadway Fort Edward, NY 12828
Death Certificate Filed District Number Register tuber
City, Town or Village �7
❑Burial Date Cemetery or Crematory
March 21, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
F= Hold Union Cemetery
G Date Point of
Transportation�:, ❑ P Shipment
0 by Common Destination
Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
1 . Remains are Shipped, If Other than Above
2. Address
Et
Ltt
C" Permission is h eby ranted to dispose of the human ains described above s indicated.
Date Issu d Registrar of Vital Statistic
(signature)
District Numbers 7 Place ,A) , CI `.7‘----;: C
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-
W Date of Disposition 3-al-2oi2_ Place of Disposition l ne U t'e(.4) Crew/44-or :vvtW
M (address)
W,;
0
X (section (lot number) (grave number)
0
Name of Sexton or Person in Charge f Premises I t'WlO*k4 he_11
` _i .“
I (please print)
Signature Title cr tri r7
(over)
DOH-1555 (02/2004)