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Lyon, Charles
NEW YORK STATE DEPARTMENT OF HEINLTHAt 441q Vital Records Section Burial - Transit Permit Name First Middle Last Sex Iv Charles Lyon Lon Male Date of Death Age I If Veteran of U.S.Armed Forces, December 22,2012 63 War or Dates I-. Place of Death Hospital, Institution or Z City, Town or Village Wilmington i Street Address 1311 Haselton Rd. `p Manner of Death ni I xi Natural Cause I 'Accident I I Homicide Suicide n Undetermined Pending Circumstances Investigation Q Medical Certifier Name Title Woods McCahill,MD Address Placid Memorial Health Center,AMC-Lake Placid,Lake Placid,NY 12946 Death Certificate Filed i District Number Register Number City, Town or Village Town of Wilmington 1567 0 Burial Date Cemetery or Crematory El Entombment December 28,2012 Pine View Crematory Andress ©Cremation 21 Quaker Rd., Queensbury,NY 12804 Date Place Removed Z I I Removal and/or Held O and/or Address I= Hold CO 0 Date ` Point of co I I Transportation j Shipment p by Common Destination Carrier n Disinterment Date Cemetery Address (�Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M.B. Clark,Inc. 01075 Address 2310 Saranac Ave.,Lake Placid,NY 12946 Name of Funeral Firm Making Disposition or to Whom i•- Remains are Shipped, If Other than Above 2 Address re W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12-24-2012 Registrar of Vital Statistics f '��4 / .Q.,(?,LSZ___ (signature) District Number 1567 Place Town of Wilmington I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: UJDate of Disposition it_N-i2 Place of Disposition -Ziail.) C►ew.../for.ur., W (address) co re (section) a (lot number) (grave number) ZZ Name of Sexton or Person in Charge of Premises /"he:iftp(,,. wN11, (please print) UJ Signature 410 Title C.V.tr wl,p--V& (over) DOH-1555(02/2004)