Lylyk Sr. John NEW YORK STATE DEPARTMENT OF HEALTH i
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John Gregor Lylyk Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 15, 2012 53 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
0W Medical Certifier _Name� n _c/ I Title ✓�0
Ir "rzvl c, ,
Adesd .t C y
CC9�' fiy1
th Certificate Filed C9 ! (U District Number S j Register Number
own or Village �` t� lei
0 Burial Date Cemetery or Crematory
April 23, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z 0 Removal and/or Held
and/or Address 1
p' Hold
C' Date Point of
u ❑Transportation Shipment
CO by Common Destination
Z' Carrier
Disinterment 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
it Remains are Shipped, If Other than Above „
2; Address
W
G.< Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued LI/ 1 i/ / 2 Registrar of Vital Statistics W
(signature)
District Number 5 60 r Place 6 (u„--,5 \ a I l S , Al V
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iii Date of Disposition 1111't(l't- Place of Disposition "1 14ttcu Coacrv___
2, (address)
111
Ce (section) (lot number) (grave number)
0 Name of Sexton or Person i Charge of remises t o> .' ,,
(please print)
W Signature - Title CO 6`A-'.1L
(over)
DOH-1555 (02/2004)