O'Dell, Lawrence NEW YORK STATE DEPARTMENT OF HEALTH It 55
Vital Records Section ' ' J Burial - Transit Permit
Name First Middle Last Sex
Lawrence A O'Dell Male
Date of Death Age-1 l If Veteran of U.S.Armed Forces,
I, July 11, 2011 1� War or Dates
2 Place of Death - Hospital, Institution or
W City,Town,or Village Glens Falls Street Address Glens Falls Hospital
G Manner of Death ®Natural Cause ❑Accident ❑Homicide Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
ti Medical Certifier Name Title
W Dr. Max Crossman MD
CI Address
Whitehall Health Center, Poultney St., Whitehall, New York 12887
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5 60 1 3 1 2.
❑Burial Date July14, 2011 Cemetery or Crematory
Pine View Crematorium
❑Entombment Address
, ❑X Cremation
` Date Place Removed
0 ❑ Removal and/or Held
and/or Address
I' Hold
Date Point of
Q ❑Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
a ❑Disinterment
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00897
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
X
W Address
O.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 'Wig 1 it Registrar of Vital Statistics itJCAM't'4t, o-''
(signature)
District Number 5 Go 1 Place Glens Falls,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 )i j, -11 Place of Disposition Pp.4,this-) CNA,.c for ic..—
2 (address)
W
0
(section) (lot n tuber) (grave number)
Name of Sexton or Pers in Charge of Pr mises C r:jk �w� -
Z (pl se print)
ILIkf
Signature f,`, Title Ciit4 M Iya.A.
(over)
DOH-1555 (02/2004)