Lyons, Helene NEW YORK STATE DEPARTMENT OF HEALTH \ �Jb
Vital Records Section t \ Burial - Transit Permit
Name First Middle Last Sex
Helene Lyons Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 26, 2014 47 War or Dates
Place of Death Hospital, Institution or
uj City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death J Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined n Pending
ill
t) Circumstances Investigation
LU Medical Certifier Name Title
Bridget Babcock, FNPC
Address
Hudson Falls, NY 12839
Death Certificate Filed District Number Register Number
City, Town or Village 5601 ,i-W
❑Burial Date Cemetery or Crematory
December 1, 2014 Pine View Crematorium
g''❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z Removal and/or Held
0 u and/or Address
F.- Hold
U) Date Point of
aEl Transportation Shipment
by Common Destination
1 Carrier
Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
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
! Remains are Shipped, If Other than Above
2 Address
IX
LU
a Permission is hereby granted to dispose of the human remains describ d above a indicated
Date Issued / Registrar of Vital Statistics
(si ture)
District Number 5601 Place
' - I certify that the remains of the decedent identified above were disposed of in accordance with this perm' on:
la Date of Disposition 12/01/2014 Place of Disposition Quaker Road Queensbury,NY 12804
W2 (address)
Cl)
Q (section) (lot number) C (grave number)
p Name of Sexton or Person in Charge of Premises t4r„1 Q-- J
Z - i please print)
W Signature t '� Title CAtt rA ''
(over)
DOH-1555 (02/2004)