Lyman, Robert NEW YORK STATE DEPARTMENT OF HEALTH Nv
IBurial - Transit Permit
Vital Records Section
Name First Middle Last Sex
� Robert N. Lyman Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 26, 2011 14 War or Dates
i" Place of Death Hospital, Institution or
1: City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
F�'
r Medical Certifier Name Title
Dean Reali, MD,
Address
Glens Falls Hospital Glens Falls, NY 12801
Death Certificate Filed District Nurria00\ Regr�te tEper
City, Town or Village T�'✓l
0 Burial Date Cemetery or Crematory
November 29, 2011 Pine View Crematorium
❑Entombment Address
'®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
i ,„ 0 Transportation Shipment
tti, by Common Destination
;0 Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
` Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
,. Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
=' Remains are Shipped, If Other than Above
Address
At-
Ian .
' Permission is hereby ranted to dispose of the human remains descr'Zayv ,(in.L%
Date Issued_/f�-29 l/ Registrar of Vital Statistics
(signature)
District Number 5/6.0/ Place C-/,2ir o ,C,Ar '.y
- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition NW 301lai' Place of Disposition RCJJu(.) Lw*-etotWO.
a (address)
Lii
_............
at -+ .
(section) /jr _ (lot number) � �- (grave number)
Name of Sexton or Person in Char of Premises WA-1 r (Aktc'
(4/ease print)
W Signature Title CVErli'Tt)e_
(over)
DOH-1555 (02/2004)