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Lyman, Dorothy Ann NEW YORK STATE DEPARTMENT OF HEALTH - Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Dorothy Ann Lyman Female Date of Death Age If Veteran of U.S.Armed Forces, 10/21/2020 79 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Hartford Town Street Address 123 County Route 17, Hartford Town, New York 12838 p Manner of Death ©Natural Cause p Accident Homicide Suicide ❑Undetermined Pending !L Circumstances Investigation W Medical Certifier Name Title C Sean Kimball DO Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Hartford 5759 13 O Burial Date Cemetery,Crematory or Facility Name 10/23/2020 Pine View Crematorium ❑Entombment Address X❑Cremation Queensbury Town,New York ❑Donation ZO ❑Removal Date Place Removed and/or and/or Held H Hold Address CO 0 O. 1-1 Date Point of Cl) ❑Transportation p by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 2 Address W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/23/2020 Registrar of Vital Statistics Denise Petteys(ECectronicaCCy Signed) (signature) District Number 5759 Place Hartford, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition lal Z �y� Place of Disposition 2 ddress/ W CC N (section) (lot number) (grave number) Name of Sexton or Person in Charg f Premises �t f,s SD^ '�{ Z (p/ee se print) /� IL Signature Title `ASA DOH-1555(07/18)p t of 2 Public Health Law Sec. 4145(2b) --4_ 14141 Receipt 1' Human remains of i delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# / ! 1