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Hurlburt, Lucius Martin
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Lucius Martin Hurlburt Male Date of Death Age If Veteran of U.S.Armed Forces, 01/11/2020 78 Years Waror Dates 1958-1960 F— Place of Death Hospital,Institution or W City,Town or Village Albany Street Address Albany Medical Center Hospital p Manner of Death ©Natural Cause Accident Homicide Suicide ❑Undetermined ❑Pending Uj Circumstances Investigation V W Medical Certifier Name Title Alice Cheung MD Address 43 New Scotland Ave,Albany,New York 12208 Death Certificate Filed District Number Register Number City,Town or Village Albany 0101 0079 Burial Date Cemetery,Crematory or Facility Name 01/14/2020 Pine View Crematorium Entombment Address X❑Cremation Queensbury Town,New York ❑Donation ZO ❑Removal Date Place Removed and/or and/or Held N Hold Address O EL. Date Point of N ❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom F Remains are Shipped,If Otherthan Above Address W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/13/2020 Registrar of Vital Statistics DanieCCe S GilTespie(ECectronicalTySigned) (signature) District Number 0101 Place Albany, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H IJ Z Date of Disposition 1 70 Place of Disposition Uj (address) W N (section) (lot number) (grave number/ 0 Name of Sexton or Person in Charge of remises (P! sse ep print) Z LU Signature Title J DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 013239 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#