Lyons, John NEW YORK STATE DEPARTMENT OF HEALTH t v 41 113
Vital Records Section Burial - Transit Permit
_- Name First Middle Last Sex
John Francis Lyons Male
ic,n Date of Death Age If Veteran of U.S. Armed Forces,
September 27, 2015 88 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address The Stanton Nusing and Rehabilitation
vr, Manner of Death J Natural Cause 0 Accident 0 Homicide 0 Suicide n Undetermined Pending
Circumstances Investigation
e Medical Certifier Name Title
�F Roslyn Socolof, M.D. Dr.
Address
100 Broad Street Glens Falls, NY 12801
Death Certificate Filed Di ct N ber a er Number
City, Town or Village Queensbury l 1
0 Burial Date Cemetery or Crematory£- September 28, 2015 Pine View Crematory
idIl=0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
0 Transportation Shipment
by Common Destination
' Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
`: Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
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 hereb granted to dispose of the human emains described ove as indicated.
Date Issued9l �ic Registrar of Vital Statistics c_,_ CA - rt�„, ,,
(signature)
g
/�'��
District Number 9cn Place ) n(-0 ( C LLAsi- ,1
certify that the remains of the decedent identified above were disposed of in acc an a with this permit on:
Date of Disposition 09/28/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
' (section) � (lot number) (grave number)
�►, g �wl,a,t L�a.n4�4 c
Name of Sexton or Person in Charge of Premises
(� (please print)
Signature "� Title C rGft o7 4_55,75-74
(over) j
DOH-1555 (02/2004)