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LyFord, Elva NEW YORK STATE DEPARTMENT OF HEALTH f- , i Burial - Transit Permit Vital Records Section Name First Middle I Last Sex Elva Loisa LyFord Female Date of Death Age If Veteran of U.S. Armed Forces, January 1, 2017 78 War or Dates ill VPlace of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death J Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending iii Circumstances Investigation a Medical Certifier Name Title Scott Biasetti, M.D. Dr. Address 100 Park Street Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls ❑Burial Date Cemetery or Crematory January 3, 2017 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address p Hold Date Point of ❑Transportation Shipment by Common Destination 3 Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address El Reinterment Permit Issued to Registration Number Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078 Address 136 Main Street, South Glens Falls NY 12803 Name of Funeral Firm Making Disposition or to Whom 1- Remains are Shipped, If Other than Above Address f Permission is hereby granted to dispose of the human remains described above s indicated. 1^ Date Issued 1 ( t-f /'20 11 Registrar of Vital Statistics C 41,_ ,Arg, (signature) District Number 5 60 1 Place 6 ( S \ 5 , Oki certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 01/03/2017 Place of Disposition Quaker Road Queensbury,NY 12804 2. (address) N i (section) (lot number) (grave number) Name of Sexton or Person in Charge of remises ��i; Je,^Ir /�,� ( lease print) Si nature a Title c 9 (over) DOH-1555 (02/2004)