Lomenzo,Anthony J. NEW YORKSTATE DEPARTMENT OF HEALTH BUrlal - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Anthony J.Lomenzo Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/22/2020 75 Years War or Dates 1968-1970
Place of Death Hospital,Institution or
WCity,Town or Village Fort Ann Town Street Address 607 West Road,Fort Ann Town,New York 12827
p Mannerof Death IN Natural Cause Accident Homicide Suicide Undetermined Pending
UCircumstances Investigation
WD Medical Certifier Name Title
Eileen Spillane DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Num1,
City,Town or Village Fort Ann 5754 7
Burial Date Cemetery,Crematory or Facility Name
04/22/2020 PineView Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
ZZ Removal Date Place Removed
and/or and/or Held
f- Hold Address
N
0
d 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 Mason Funeral Home 01117
Address
18 George St Po Box 277,Fort Ann,New York 12827-0277
Name of Funeral Firm Making Disposition or to Whom
�- Remains are Shipped,If Other than Above
Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/22/2020 Registrar of Vital Statistics Barbara J Winchell(Electronically Signed)
(signature/
District Number 5754 Place Fort Ann, 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 41-Z2-7020 Place of Disposition / Y►Q,
W
(address/
W
N
cc (section) (lot number) (grave number/
0 Name of Sexton or Person in Ch f Premises
Z (please print)
W Signature Title L/GMat��i� p a. eY/
DOH-1555(07/18)p 1 of 2
� M
Public Health Law Sec. 4145(2b) 013 6 0 2
Receipt
Human remains of; ' `' i, delivered on r ! , 20
Pine View Cemetery Representing the funeral home named ofn,burial permit
Official Funeral Directors Reg.or License# f