Lavin, Francis NEW YORK STATE DEPARTMENT OF HEALTH Burial - Trans t U3u .t
Vital Records Section
— Name First Middle��" Last Sex
Francis W. Lavin Male
Date of Death Age If Veteran of U.S.Armed Forces,
1" September 10, 2011 50 War or Dates
Z Place of Death Hospital, Institution or
W City,Town,or Village Hartford Street Address Route 149
G Manner of Death El Natural Cause El Accident El Homicide ESuicide n Undetermined n Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Dr. Max Crossman MD
0 Address
Whitehall Health Center, Poultney St., Whitehall, New York 12887
Death Certificate Filed District Number Register Number
City,Town or Village Hartford
❑Burial Date Cemetery or Crematory
September 15, 2011 Pineview Crematorium
❑Entombment Address
®Cremation Queensbury, NY 12804
Date Place Removed
0 n Removal and/or Held
i. and/or Address •
Hold
0 Date Point of
0 Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
5 El
Disinterment
r
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
X
W Address
Q.
Permission is he !by anted to dispose of the human remain scribed a e indicated.
Date Issued [ 14 t l Registrar of Vital Statistics ,
(signature)
District Number 5''1 SR Place Hartford,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
'Date of Disposition 1111,14 Place of Disposition Pineview Crematorium
W (address)
Ih
4
(section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises dr-itii r SW ease print)
Signatureg4/ Title CMIF ,
(over)
DOH-1555 (02/2004)