Lashinsky, Lyon NEW YORK STATE DEPARTMENT OF HEALTH r 1 3g3
Vital Records Section Burial - Transit Permit
•
Name First Middle Last Sex
Lyon Daniel Lashinsky Male
Date of Death Age If Veteran of U.S. Armed Forces,
05/28/2015 0 years War or Dates
# Place of Death Hospital, Institution or
W City, TcXXXID at Y Glens Falls Street Address Glens Falls Hospital
p Manner of Death in latural Cause 0 Accident D Homicide D Suicide Undetermined ❑Pending
IL/ Circumstances Investigation
W Medical Certifier Name Title
l Mary Beth Manrigue C N M
Address
102 Park Street Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, TAM*li? 6X Glens Falls 5601 5
><i ❑Burial Date Cemetery or Crematory
•
05/29/2015 Pine View Crematorium
❑Entombment Address• .
:::i [ 'Cremation Queensbury, NY 12804
Date Place Removed
Removal and/or Held
and/or
Address
It Hold
U) _
O Date Point of
kD Transportation Shipment
0 by Common Destination
Carrier
Disinterment - Date • Cemetery Address
Reinterment Date Cemetery Address .
Permit Issued to • Registration Number
• , Name of Funeral Home Mason Funeral Home 01117
Address
P O Box 277 Fort Ann, N Y 12827
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
• Address
CZ
111.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/29/2015 Registrar of Vital Statistics (./J
(si ature)
District Number 5601 Place Glens Falls
/v V
t
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �
l V Date of Disposition /i/is" Place of Disposition 'ltC,..,,.oiort,
2 (address)
ui
to
cc (section) ,(lot number)� (grave number)
Ca ��
Name of Sexton or Person in Charge of Premises it"dal
* ► (please print)
• Signature A.
�- J Title M
(over)
DOH-1555 (02/2004) •