Lyman,Cynthia M. # -�yg
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Sex
Name First Middle Last
Female
Cynthia M Lyman
Date of Death Age If Veteran of U.S.Armed Forces,
11/08/2019 69 Years War or Dates
H= Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
W' Manner of Death Undetermined Pending
`Q ®Natural Cause Accident Homicide Suicide
UJI Circumstances Investigation
0 Title
W Medical Certifier Name
a Gwendolyn Morris-Dickinson PA
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 484
Burial DateJ Cemetery,Crematory or Facility Name
11/12/2019 Pine View Crematory
❑Entombment Address
Cremation Queensbury Town,New York
❑Donation
Date Place Removed
Removal and/or Address and/or Held
N
Hold
Date Point of
N E Transportation Shipment
p by Common
Carrier Destination
I
Date Cemetery Address
Disinterment
Reinterment
Date Cemetery Address 10
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
W
CL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/12/2019 Registrar of Vital Statistics �R96ertAndrew Curtis(ECectronicallySigned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition III(3I1 Place of Disposition ✓ ( fir+
(address)
2
W
W /section) (lot number/ (grave number)
0 Name of Sexton or Person in Charge of Premises
( ease print)
W Signature (.✓�_ Title r
DO H-1555(07/18)p 1 of 2
I
I
Public Health Law Sec. 4145(2b) 1,'1 0 7 J ;
Receipt
Human remains of delivered on , 20
Pine View Cemetery R p nfing-the,,ri t re al home named on burial permit
Official Funeral Directors"Reg. or License# =' '
i