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Lysobey, Denise M. thitr NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Denise M.Lysobey Female Date of Death Age If Veteran of U.S.Armed Forces, 10/14/2020 63 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital WW Manner of Death ©Natural Cause 1:1Accident Homicide Suicide El Undetermined Pending Circumstances Investigation 2 Medical Certifier Name Title Kasandra Frasier PA Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 470 0 Burial Date Cemetery,Crematory or Facility Name 10/15/2020 PineView Crematorium 0 Entombment Address 0 Cremation Queensbury Town,New York 0 Donation Removal Date Place Removed and/or and/or Held p N Hold Address 0 O. Date Point of ❑ U) Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Mason Funeral Home 01117 Address 18 George St Po Box 277,Fort Ann,New York 12827-0277 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above 2 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/15/2020 Registrar of Vital Statistics Robert Andrew Curtis(Electronically Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition p1 AD 110 Place of Disposition (address) W (section) t nu ber) (grave number) O roi l.. NNy{ Name of Sexton or Person in Cha f Premises Z tt (please int) W rt*Wit Signature Title ` DOH-1555(07/18)p 1 of 2 i Public Health Law Sec. 4145(2b) 0141 Receipt 1'4, I Human remains of 1.. .' / 1 - , / . ,. delivered on ./ ' i" ./. --' , 20 Pine View Cemetery Representing the funeral home namecl,maihmial permit Official Funeral Directors Reg.or License# ' " - ' /