Anslow, Lyanne G . Z
NEW YORK STATE DEPARTMENT OF HEALTH (11
Vital Records Section Burial - fransii Permit
Name First Middle Last Sex
Lyanne Anslow Female
Date of Death Age If Veteran of U.S. Armed Forces,
06/28/2016 77 years War or Dates
-- Place of Death Hospital, Institution or
Z City, Td®O(t MUM( Glens Falls Street Address Park St Glens Falls, N Y 12801
0 Manner of Death Natural Cause El Accident El Homicide El Suicide ❑Undetermined ❑Pending
S. Circumstances Investigation
0.
ILI Medical Certifier Name Title
William Cleaver Attending Physician
Address
100 Park St Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, TaWar=146X Glens Falls 5601 328
NI❑Burial Date Cemetery or Crematory
06/29/2016 Pine View Crematory
0 Entombment Address
13'Cremation Queensbury, NY
Date Place Removed
Z El Removal and/or Held
and/or Address
H Hold
!i
0
Date Point of
IA Transportation Shipment
3 by Common Destination
Carrier
Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Edward L. Kelly Funeral Home 00519
Address
Schroon Lake, N Y 12870
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
U
▪ Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/29/2016 Registrar of Vital Statistics (,,,n) 9. W k'1
(signnat e)
District Number 5601 Place Glens Falls,e&1 y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LU Date of Disposition (o ()0 fro Place of Disposition 4 61 U ^ ( t4oi o.''
(address)
LEE
tfl
1l (section) (lot number (grave number)
0 Zt 'i Name of Sexton or Person in Charge of Premises if
2 0 (please print)
Signature t Title 4' C�tr'p gat
(over)
DOH-1555 (02/2004)