Lebenson, Florence NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Florence Lebenson Female
Date of Death Age If Veteran of U.S. Armed Forces,
01/15/2018 87 Years War or Dates
1-- Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
IN
pManner of Death J Natural Cause El Accident ❑Homicide ID Suicide El Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
d Shahid Ahmed MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 26
❑Burial Date Cemetery or Crematory
01/16/2018 Pine View Crematory
❑Entombment Address
k,..4.®Cremation Queensbury Town, New York
7� Date Place Removed
Q❑Removal and/or Held
I— Address
Address
«.- Hold
v
0 Date Point of
❑Transportation Shipment
by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
S. Address
it
E't" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01J17/2018 Registrar of Vital Statistics w9bertA Curtis(ECectronicallySigned)
(signature)
District Number 5601 Place Glens Falls, New York
1,,, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
144 Date of Disposition (Jz. iIic Place of Disposition frKIL (�.ricia�
W. (address)
pX (section) i1ot number (grave number)
Name of Sexton or Person in Charge of Pre -ses ('<'tp ,r 3 abt
(pi se print)
Signature tr Title (OE.m tr6-
(over)
DOH-1555 (02/2004)