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Lyons, Richard NEW YORK STATE DEPARTMENT OF HEALTH /3j Vital Records Section Burial - Transit Permit Name First Middle Last Sex Richard Charles Lyons Male Date of Death Age If Veteran of U.S. Armed Forces, February 12, 2017 82 War or Dates of Death Hospital, Institution or W own or Village Glens Falls Street Address Glens Falls Hospital CI anner of Death X❑Natural Cause El Accident El Homicide ❑ Suicide 1-1 Undetermined Pending litCircumstances Investigation W Medical Certifier Name Title a James North, M.D Address 100 Broad St. Glens Falls, NY 12801 Qeath Certificate Filed , District Number Register Nu ity„)Town or Village '� ..,,1-c .1(., (1 S 5601 /0 ❑Burial Date Cemetery or Crematory February 15, 2017 Pine Vew Crematorium ❑Entombment Address ©Cremation Queensbury,NY 12804 Date Place Removed 2 ❑ Removal and/or Held and/or Address F. Hold 03 Date Point of eL ❑Transportation Shipment t/1 by Common Destination a Carrier ElDisinterment 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 I_-° Remains are Shipped, If Other than Above 2 Address W 0 Permission is hereby granted to dispose of the human remains.de cribed abs e as indi ted. Date Issued Registrar of Vital Statics Z,(Z �y ,,//A i,Ae'. sign ure) District Number 5601 Place 4 / J //-�x�,��1 I certify that the remains of the decedent identified above were disposed of in accordance wi this permit on: W Date of Disposition 02/ 2017 Place of Disposition Queensbury,NY 12804 !/ , ,t,)`_,Ie e,,Lcr y 2 (address) L! CO Ce (section) 1 (lot umber) (grave number) pName of Sextott]]..��r Pers in Charge of Premises ,l i.� /e4-1 �rl-141 ?,e-4 6` j I( (please print) W Signature / 1 Title C-ce-.y�c- C'fr e),7t'•/'c: Gl'-- (over) DOH-1555 (02/2004)