Lyon, Gilbert NEW YORK STATE DEPARTMENT OF HEALTH 7-1
Vital Records Section e 1 Burial - Transit erm it
Name First Middle Last Sex
6-I1./3.6 H7)/Z T III/ L. %D IV MAL E
Date of Death Age If Veteran of U.S. Armed Fprces,
, AiA/ 1 �01,3 2.. War or Dates N/A
t-_� Place of Death S A/z^�1A L LA)LC. Hospital, Institution or A1--j G- SAn-#4Nf k.U- [.A6
6 City,TOW-03r Village A1.4 iza,, 7-1;mud Street Address SAy641 m i. L u<jg 1 ivy
0 Manner of Death L Natural Cause 0 Accident 0 Homicide 0 Suicide El Undetermined ri Pending
iii
Circumstances Investigation
t1 Medical Certifier Name Title
0: AAA/4 60aEft y I-4 P
Address
Ai-rc - SSA,z,,o,✓ao& LA Ice. , SAizA4vAG L 4ke. /Ly /Z'/ J
Death Certificate Filed District Number]//5 Register Number
City‹-T-Wrt or Village NA e l:i Tp�i.) 6 D
❑Burial Date Cemetery or Crematory
❑Entombment AddIVA" /3 �/ 3 ,/ L//ec�.J C/ZcP t/ATatL1
jgCremation vA/ , /LZ / a cieen.J do -f ti
Date Place Remov d
Z❑Removal and/or Held
Pand/or Address
Hold
0 Date Point of
t 0 Transportation Shipment
in by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home /�,4,"JAM // /C . Ol 0 c
Address
3/0 $412AIIJ L IV(/cr j LA 16e. P G1d Ny /Z2 V‘
Name of Funeral Firm Making Disposition or to Whom
f- Remains are Shipped, If Other than Above
2 Address
Ili
I LI
an Permission is hereby granted to dispose of the human rK
ins described as indicated.
Date Issued s`3�./0j� Registrar of Vital Statistics �
nature)
District Numberlo Place Village of Saranac Lake i
1.. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
LU Date of Disposition c%t4 �3 Place of Disposition �,�,,Jrw Otrmse orto._
W (address)
to
Q (section) C' (grave number)
p Name of Sexton or Person in Charg of Premises 4,poitnuttiLber)
riJ,o,�..t�► (pleprint)
Ui
Si nature ( I.L.. Title Cf '�i'`'i14TC�Y�.
9
(over)
DOH-1555 (02/2004)