Lapham, Jr. Byron NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
AA Name First Middle Last Sex
Byron Jerome Lapham Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/31/2018 88 Years War or Dates Korea
Place of Death Hospital, Institution or
irii City, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
riti Manner of DeathoLu Natural Cause El Accident El Homicide EiSuicide riUndetermined Pending
Circumstances Investigation
ital Medical Certifier Name Title
Philip Gara MD
Address
Val 319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City, Town or Village Fort Edward 5755 62
❑Burial Date Cemetery or Crematory
10/31/2018 Pine View Crematory
tbt,f❑Entombment Address
®Cremation Queenbury, New York
kit Date Place Removed
- ❑Removal and/or Held
and/or
Address
Hold
d Date Point of
at
L]Transportation Shipment
by Common Destination
ill Carrier
,,e,❑Disinterment Date Cemetery Address
-44
Li Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
''i, Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
XI Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
- Date Issued 10/31/2018 Registrar of Vital Statistics Aimee Mahoney((fectronicaiCyStgned)
(signature)
til District Number Place
5755 Fort Edward, New York
vAr-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
11 Date of Disposition )I /( `]f Place of Disposition gnIke (,..)1or.--
(address)
ii
(section) (lot number) (grave number)
Name of Sexton or Person inCharge of Premises
0r,. S
6:4
/ (p/ ase print)4=3,, Signature ./ Title CREtri4 T/L
(over)
DOH-1555 (02/2004)