Been, Lucille NEW YORK STATE DEPARTMENT OF,HEALTH Burial - Transit Permit(?)
Vital Records Section
Name First Middle ` Last Sex
Lucille K. Been Female
-: Date of Death Age If Veteran of U.S.Armed Forces,
06/26/2015 77 War or Dates No
-; Place of Death Hospital, Institution t
Z City,Town or Village City of Albany or Street Address St. Peter's Hospice
O Manner of Death Natural Undetermined Pending
W ® Cause El Natural Homicide ❑ Suicide El ❑ Investigation
W Medical Certifier Name Title
0 Thea Dalfino MD
Address
315 S. Manning Blvd. Albany, NY
• Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 1354
Date Cemetery or Crematory
El Burial 06/26/2015 Pine View Crematory
❑ Entombment Address
® Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
0 ❑ and/or H Address
Hold
0 Date Point of
p_ Transportation Shipment
Cl) ❑ By Common Destination
p Carrier
❑ Disinterment
Date Cemetery Address
❑ Date Cemetery Address
Reinterment
y . Permit Issued To Registration Number
Name of Funeral Home Brewer Funeral Home, Inc. 00211
Address
24 Church St. Lake Luzerne, NY 12846
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
2 Address
Ili
Q. Permission is hereby granted to dispose of the human remains described above as indic d.
Date 06/26/2015 Registrar of Vital Statistics �"'''`� -'Q `-��
Issued (signature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were' disposed of in accordance with this permit on:
I`- Date of Disposition re
Place of Disposition ?Ile ci c'Pw CPe wia(ortwr44
(address)
w
R/)'
CC (section) (lot number) (grave number)
0
W Name of Sexton or Person in Charg- of Premises I t'M i �N.0 e
(please print'
Signature . _,.�../ f,. . Title C reriria r+r Ili
st
(over)
DOH-1555 (02/2004)