Varney Sr., Lewis NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
e,, Name First Middle Last Sex
Lewis L. Varney,Sr. Male
n Date of Death Age If Veteran of U.S. Armed Forces,
January 27,2012 89 War or Dates World War II
.. Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
tit
ice° Manner of Death I XI Natural Cause I I Accident [1 Homicide Suicide Undetermined Pending
V Circumstances Investigation
u Medical Certifier Name Title
Dr Siddicci,MD
Address
Fort Edward,NY
:; Death Certificate Filed District Number Register Number
City, Town or Village Fort Edward,NY 5755 3
D Burial Date Cemetery or Crematory
March 30,2012 St. Alphonsus Cemetery
❑Entombment Address
❑Cremation Pine Street, Queensbury,NY
Date— Place Removed _ _
Z I I Removal and/or Held
O and/or Address
H Hold
N
0 Date Point of
1,35 I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date I Cemetery Address
Reinterment Date Cemetery Address
ti'' Permit Issued to Registration Number
a' Name of Funeral Home Singleton-Healy Funeral Home 01596
Address
407 Bay Road, Queensbury,NY 12804
° Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
l
1
Permission is hereby ranted to dispose of the human remai describe bode as indicated.
Date Issued—.? /� Registrar of Vital Statics �,„ u pad
(signature)
_. District Number 5755 Place Fort Edward,NY
I certify that the remains of the decedent identified abovesliy r di osed of in apcordancq wi (this perm' on ,1;
Z Date of Disposition I Z. Place of Disposition i Mon l
W P 313�` / adore
ce (se lion) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises Li V'
Z " (please print)
W Title rOQ11Gq Li
Signature ``
(over)
DOH-1555(02/2004)