Lavin, Owen NEW YORK STATE DEPARTMENT OF HEALTH4 • - 1
Vital Records Section Burial - Transi ermit
Name First Middle Last Sex
Owen A Lavin Male
Date of Death Age If Veteran of U.S.Armed Forces,
I. January 1, 2017 77 War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Whitehall Street Address Residence
0 Manner of Death Ell Natural Cause n Accident n Homicide nSuicide Undetermined El Pending
W Circumstances Investigation
0 Medical Certifier Name Title
al 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 Whitehall `
❑Burial Date Cemetery or Crematory
January 6, 2017 Pineview Crematorium
n Entombment Address
Q Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
4 n Removal and/or Held
and/or Address
i' Hold
0 Date Point of
0 El Transportation Shipment
0. by Common Destination
Carrier
Date Cemetery Address
Disinterment
11 Date Cemetery Address
n Reinterment
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
ft
W Address
a.
Permission is hereby granted to dispose of the human remains described� � above as indicated.
Date Issued 1-5 odQ)7 Registrar of Vital Statistics 0,hit Q'L2 y `4, &
0 (signature)
District Number 57c ? Place Whitehall,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 01/06/2017 Place of Disposition Pineview Crematorium
2 (address)
W
N
0 (section) A.(lot number( (grave number)
CIName of Sexton or Person in Charge of Pre " es L 4r�; r h"Nt1�
Z ( lease print)
W Title ((�f m
Signature i
(over)
DOH-1555 (02/2004)