Lehine, Lydia NEW YORK STATE DEPARTMENT OF HEALTH `33
Vital Records Section / Burial - Transit Permit
Name First Middle Last Sex
Lydia Lehine Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 20, 2012 88 War or Dates
iPlace of Death • Hospital, Institution or
; City, Town or Village Queensbury Street Address 44 Willowbrook Road
Manner of Death 0 Natural Cause Ei Accident ElHomicide Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
John Sawyer MD
Address
161 Carey Road Queensbury,NY 12804
Death Certificate Filed I District Number Register Number
City, Town or Village Queensbury 5657 /6
❑Burial Date Cemetery or Crematory
❑Entombment August 20,2012 Pine View Crematorium
Address
®Cremation 21 Quaker Road, Queensbury,NY 12804
r-� Date Place Removed
Z l i Removal and/or Held
C and/or Address
F' Hold
N
0 Date Point of
N n Transportation Shipment
p by Common Destination
Carrier
E
Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
's:c- 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
1* Remains are Shipped, If Other than Above
Address
' Permission is hereby granted to dispose of the human r, ains described abo = .s indicated.
Date Issued I-. -ot,. Registrar of Vital Statistics /
Iir_
(signatu,)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed
�of in accordance with this permit on:
tu Date of Disposition V-t3-IZ Place of Disposition X,,,4 Vw l r..�'
utor,M.-
lJJ (address)
Cl)
C (section) (lot numbers (grave number)
ZitName of Sexton or Person in Charge of Premises 1,�,�� t', 6%-t
W //1 1 (please print)
Signature l� Title Cnr�.-p�VA
J
(over)
DOH-1555(02/2004)