Lonsdale, Stephen NEW YORK STATE DEPARTMENT OF HEA!,,TH ; ' f 1 o( I
Vital Records Section - , It Burial - Transit Permit
Name First Middle Last Sex
Stephen Lonsdale Male
Date of Death Age If Veteran of U.S.Armed Forces,
I. January 1, 2014 SiWar or Dates
Z Place of Death Hospital, Institution or
W City,Town, or Village Whitehall Street Address
o Manner of Death ❑ Natural Cause 0 Accident 0 Homicide Q Suicide 0 Undetermined x0 Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W Mrs. Ruth Scribner Coroner
0 Address
Whitehall, NY 12887
Death Certificate Filed District Number Register Number
City,Town or Village Whitehall 5`7 1c 1f ,
ElDate CemeteryCremato
Burial January 11, 2014 or Pine View Crematorium
❑ Entombment Address
Cremation 21 Quaker Road Queensbury New York 12803
au 0
2 Date Place Removed
0 ❑ Removal and/or Held
- and/or Address
l' Hold
0 Date Point of
0 n Transportation Shipment
t by Common Destination
Carrier
Date Cemetery Address
Ei 0 Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
I-- Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
W Address
0.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued I 1 10) 1i4 Registrar of Vital Statistics U_1L a 111.f4, ,•( ,(-
(signature)
District Number 5 1 L 4` Place Whitehall,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z p
W Date of Disposition (/ Iiq Place of Disposition 'Gnc ++a 64a+,,
W (address)
rn
0 (section) of number) J (grave number)
O Name of Sexton or Person in Charge of Pr mises ,,+ /' thK(
W / (pl se print)
Signature G Title Men&
(over)
DOH-1555 (02/2004)