Lemery, Lawrence NEW YORK STATE DEPARTMENT OF HEALTH �
ii
Vital Records Section
Burial - Transit �ermlt
Name First Middle Last Sex
`, Lawrence Leo Lemery Male
Date of Death Age If Veteran of U.S. Armed Forces,
,_ June 18, 2018 94 War or Dates World War II
wPlace of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 218 Queensbury Ave
Manner of Death X❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
W. Circumstances Investigation
0.
W Medical Certifier Name Title
Robert Evans,
I Address
One Irongate Center Glens Falls, NY 12801
Death Certificate Filed District Nupa�r Register Number
City, Town or Village "D
g ❑Burial Date Cemetery or Crematory
i-, June 20, 2018 Pine View Crematorium
a ❑Entombment Address
,- ,®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z,,❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
O Carrier
a. Date Cemetery Address
❑ Disinterment
w ❑ Reinterment Date Cemetery Address
.. Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
fir, Address
IOC
Et.= Permission is hereby granted to dispose of the human rema' s rite a icate
Date Issued (Q - .0—t Registrar of Vital Statistics .�
(signature)
District Number (c --'1 PlacePlace c)Urn. C ttiev,,/]
I certify that the remains of the decedent identified abov w re disposed of in cordance ith this permit on:
.W= Date of Disposition 06/20/2018 Place of Disposition ���Quaker Road Queensbury,NY 12804
(address)
Co
(section) // (lot number) (grave number)
r Name of Sexton or Person in Charge of Premises /(n,t�L 4.,,,A'
, ' /� ( lease pn
.. Signature (-( L Title q RA
(over)
DOH-1555 (02/2004)