Lavery, John Town ot n
Cer fcatioof Cremation ion
Pine View Cemetery and Cremat
ory
This ccniflcs tam the remains of. Sohn Lavery
wcm cmmatW on AVnl 15 2020 at dee Pine Vicw
(MmnW) (Day)
Crematonum, Quxnsbury, New York and these are the coenw W remains of said body.
Date of Dcath onni to 2020 Age r0
- _ — (Mama) (nay)
Funeral Dome /Regan Denny Stallord Registered No. U2
(Autam zed turc)
Lavery
NAME John Lavery Apn70
L Owner: Robert Lavery
Eoe; Mohican 47-H Grrve 21
OMe: Urn
D : 4/10/2020 Inwrndg/28/2020
Ywrt Home: Regan Denny Stafford
Gmr<ry, Pine View
# 31Z
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
John Lavery Male
Date of Death Age If Veteran of US.Armed Forces,
04/10/2020 70 Years War or Dates
r Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address The Stanton Nursing And Rehabilitation Centre
W
`p Mannerof Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
WMedical Certifier Name Title
Wendy Steinhacker PA
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 65
Burial Date Cemetery,Crematory or Facility Name
04/14/2020 Pine View Crematory
Entombment Address
0 Cremation Queensbury,New York
Donation
z Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
O
tZ Date Point of
N ❑Transportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition orto Whom
�— Remains are Shipped,If Otherthan Above
Address
Q
W
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/13/2020 Registrar of Vital Statistics CaroCrnextgardBarAer(ElectrnnrcatySrgned)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F
Z Date of Disposition qj If Place of Disposition
W (address)
2
W
U) (section/ t number/ (grave number)
8 Name of Sexton or Person in Charge of Pr miser r
z (p111S.P11,711
W Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 013538
Receipt
'C
Human remains of delivered on , 20—
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#