Lyons, James III . 1k a 4III
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
__ " Name First Middle Last Sex
James E. Lyons Male
k sf° Date of Death Age If Veteran of U.S. Armed Forces,
February 17,2015 69 War or Dates
a Place of Death Hospital, Institution or
City, Town or Village Bolton Street Address 926 East Schroon River Road
Manner of Death I Xy Natural Cause Accident Homicide Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
P Suzanne Bergin
;`-_ Address
3767 Main Street,Warrensburg,NY 12885
Death Certificate Filed District Number Registerte�a Number
City, Town or Village Bolton 5 �c�0 03
0 Burial Date Cemetery or Crematory
February 23,2015 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
H Hold
co
O Date Point of
u) I I Transportation Shipment
ci by Common Destination
Carrier
L I Disinterment Date Cemetery Address
[ I Reinterment Date Cemetery Address
_f Permit Issued to Registration Number
x Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
- ° Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
I Address
Permission is hereby ranted to dispose of the human remains describ d abo as indicated.
---)
ft a Date Issued 2 1 q l�5 Registrar of Vital Statistics � .i„�
l (signature)
, District Number 5(..P5C) Place Bolton k--1 LC-3 (--10,6
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition Z I2tiikr Place of Disposition int t'-✓ C,-i-,P
2 (address)
W
CO
Ce (section) (lnumber) , (grave number)
pName of Sexton or Person in har a of Premises Pi^,''?
Z (pleas e+print)
w Signature Title _ (W41 VJ
(over)
DOH-1555(02/2004)