Lashway, Brian 4
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Per It
Vital Records Section
Name First Middle Last Sex
Brian J Lashway Male
Date of Death Age If Veteran of U.S. Armed Forces,
>r June 27, 2017 38 War or Dates
`'' Place of Death Hospital, Institution or
City, Town or Village Hudson Falls Street Address 37 Margaret Street
• Manner of Death ❑X Natural Cause n Accident ❑Homicide ❑Suicide ❑Undetermined n Pending
W.
Circumstances Investigation
Medical Certifier Name Title
John Stoutenberg,MD
Address
Glens Falls,NY
- Death Certificate Filed District Number Register Number
City, Town or Village Hudson Falls 5726 /�
❑Burial Date Cemetery or Crematory
El Entombment June 29,2017 Pine View Crematorium
Address
®Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z ❑Removal and/or Held
and/or Address
E Hold
CO
O Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
l i Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
ME Address
U —
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued t S,--f//7 Registrar of Vital Statistics clrt-yt .c..ri A
(signature)
District Number 5726 Place Hudson Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition (P IZ111 Place of Disposition -FAA uo./ Ctowit0ria
2 (address)
W
CO
O (section) // (lot number- (grave number)
Q Name of Sexton or Person in Charge o Premises l/�1 ( ' J fWAltf
Z �i (j ease print)
W Signature u Title I �►NtOI11
(over)
DOH-1555(02/2004)