Lombardo, Elvira NEW YORK STATE DEPARTMENT OF HEALTH ` 11,
Vital Records Section Burial - Transit Permit
M` Name First Middle Last Sex
Elvira M. Lombardo 7emale
Date of Death Age If Veteran of U.S. Armed Forces,
Feb. 08, 2012 69 yrs. War or Dates no
wi Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death but Natural Cause Accident n Homicide Suicide riUndetermined 0 Pending
Circumstances Investigation
Medical Certifier Name Title
0 Jennifer L. Stratton, MD.
Address
161 Carey Rd. , Queensbury, NY. 12804
I Death Certificate Filed District Number • Register Number
Mii City, Town or Village Glens Falls 5601 55
Date Cemetery or Crematory
❑Burial Feb. 09, 2012 PineView Crematorium
Address
Cremation Queensbury, NY. 12804 .._
Date Place Removed
Z❑Removal and/or Held
.•• and/or Address
MHold
0 Date Point of
Nu Transportation Shipment
E by Common Destination
Carrier
Disinterment Date Cemetery Address
:H ElReinterment Date Cemetery Address
iiil Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
18 George St. , Fort Ann, NY. 12827
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
W
Permission is hereby granted to dispose of the human remains described above as indicated.
imi
iiiiiii Date Issued 2/0 9/1 2 Registrar of Vital Statistics
(signattil
iiiiiiill
Mi District Number 5601 Place City of Glens Falls, NY.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-E Date of Disposition FAA 11 2011 Place of Disposition +u i)4�+ Cevocti`'•-
2 (address)
MI
fX (section) _ ,(lot numbV" (grave number)
GName of Sexton or Per on in Charge o Premises r yfi e,.e({
F (please print)
l! Signature Title Cal m fTo2,,
(over)
DOH-1555 (9/98)