Dye, Lyle NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
t Male
Lyle D e
Date of Death Age If Veteran of U.S.Armed Forces,
11/12/2019 89 Years War or Dates 51-54
N Place of Death Hospital,Institution or
City,Town or Village Johnsburg Town Street Address Elderwood at North Creek
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p Manner of Death ®Natural Cause Accident El Homicide ❑Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
Ib Medical Certifier Name Title
0 James Hindson MD
£sx
t Address
112 Ski Bowl Rd,Johnsburg Town,New York 12853
Death Certificate Filed District Number Register Number
City,Town or Village North Creek 5655 47
Burial Date Cemetery,Crematory or Facility Name
11/15/2019 Pine View Crematory
❑Entombment Address
Cremation Queensbury Town,New York
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Donation
Date Place Removed
0 Removal and/or and/or Held
P, Hold Address
'a Date Point of
N Transportation Shipment
Q by Common
Carrier Destination
Date Cemetery Address
ElDisinterment
Reinterment Date Cemetery Address
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
Remains are Shipped,If Other than Above
Address
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Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/14/2019 Registrar of Vital Statistics KpthCeen C.Gorak(ECectronicalTySigned)
/signature/
District Number 5655 Place North Creek, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 11114111 Place of Disposition nt��
/address/
W
U (section) /lot number/ (grave number)
Name of Sexton or Person in Chyge of Premises r a l
/J /p! se print/
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Signature G/✓� �� Title
DO H-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) 0 1 3 C O
Receipt
Human remains of �P delivered on , 20_
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#