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Lee Jr, Lothrup
NEW YORKSTATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Lothrop Lee Jr. Male Date of Death Age If Veteran of U.S. Armed Forces, 10/25/2019 83 Years War or Dates 1958-1961 Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital W Manner of Death ©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑ Pending � Circumstances Investigation y1 Medical Certifier Name Title G John Sawyer MD Address 9 Carey Road, Queensbury Town, New York 12804 Death Certificate Filed ---75601 District Number Register Number City, Town or Village Glens Falls 465 ❑ Burial Date Cemetery, Crematory or Facility Name ❑ Entombment 10/28/2019 Pine View Crematorium Address MCremation Queensbury, New York ❑ Donation Z Date _7Place Removed � ❑Removal and/or Held and/or Hold Address Date Point of U) Q ❑ Transportation Shipment by Common Carrier Destination ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd, Queensbury, New York 12804 Name of Funeral Firm Making Disposition or to Whom �.. Remains are Shipped, If Otherthan Above 'g Address Q lllu IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/28/2019 Registrar of Vital Statistics WpbertAndrew Curtis (EfectronicafCv Signed) (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: %� Date of Disposition 16111111 Place of Disposition /address/ (section) (lotnum / (grave number) Name of Sexton or Person in Charge of Premises .4, VL z (please print) W r Signature Title DOH-1555 (07/18) p 1 of 2 Public Health Law Sec. 4145(2b) 013030 Receipt Human remains of f, Pine View Cemetery Official delivered on , 20 Representing the funeral home named on burial permit Funeral Directors Reg. or License #