Lutz, Jean NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jean K. Lutz female
Date of Death Age If Veteran of U.S. Armed Forces,
Aug. 15, 2015 93 yrs. War or Dates no
- Place of I-ath Hospital, Institution or
W Cit , ow r Village Fort Ann Street Address 1712 Co. Rte. 16
Ma - . Death Q Natural Cause 0 Accident 0 Homicide 0 Suicide ri Undetermined ri Pending
Circumstances Investigation
W Medical Certifier Name Title
G4 Jennifer L. Stratton MD.
Address
14 Manor Drive, QueP xisbu NY. 128-04
;< Death ertificate Filed District Narfiber Register Number
City own Village Fort Ann 5754 11
.1DBurial Date Cemetery or Crematory
Aug. 17, 2015 PineView Crematorium
Si, ❑Entombment Address
EtCremation Queensbury, NY
Date Place Removed
Z 9
Removal and/or Held
❑and/or
F; Address
Hold
l
0 Date Point of
IliTransportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date (Cemetery Address
Q Reinterment Date Cemetery Address
iiiiiiPermit Issued to Mason Funeral Home Registration Number
Name of Funeral Home 01 1 1 7
i . Address 18 George St. , Fort Ann, NY. 12827
Name of Funeral Firm Making Disposition or to Whom
} ► Remains are Shipped, If Other than Above
a Address
1
Ili
:,` Permission is hereby granted to dispose of the human re ns described a16 s indicated.
Date Issued /�f/..Registrar of Vital Statistics ` �..1.
/ / ^' (signature)
District Number 5754 Place Town of Fort Ann, NY.
#-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 4- t^/( Place of Disposition gclir,,r relire,'tafr✓
(address)
.tUE
Ul
CC (section) n(lotnumber) f (grave number)
ta Name of Sexton or Person in Charge of Premises (''1 s'�o""
At
(pace print)
Signature ' Title f 11,14
(over)
DOH-1555 (02/2004)