Lytz, Dianne NEW YORK STATE DEPARTMENT OF HEALTH *4 A 1 3r,
1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
4 g Dianne J. Lytz Female
Date of Death Age If Veteran of U.S. Armed Forces,
ss� May 1,2017 66 _ War or Dates
0- Place of Death Hospital, Institution or
= City, Town or Village Chester Street Address 45 William Elford Drive
mit
Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
Paul Bachman MD
m't Address
€g 3767 Main Street,HHHN,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
❑Entombment May 3,2017 Pine View Crematory
Address
0 Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
Hold
U)
O Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
"` Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
_� Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
a Permission is hereby granted to dispose of the human remains described ve a&indicated.
- : - 9 `
e Date Issued ®1 Re istrar of Vital Statistics a
(signature)
x District Number cl U ,D... Place T/O Chester,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z P
wDate of Disposition 513 in Place of Disposition ,7t,n, 1" l etas.
2 (address)
CO
Ce
O (section) li (lot number) C (grave number)
p Name of Sexton or Person in Charge of remises r. �nnllt
Z (pl&ase print)
W
Signature It ,? Title /5 Er f TDt
(over)
DOH-1555 (02/2004)