Crossman Jr, Lloyd NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
_ Lloyd D. Crossman Jr Male
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X.
Date of Death Age If Veteran of U.S.Armed Forces,
4/8/9 3 2 8 War or Dates No
.. .......:............ .. .. ........ ............................... ....... .: .........
Z Place of Death Hospital, Institution or
. City Town or Village Town of Argyle Street Address Route 40 Town of Argyle
WManner of Death Natural Cause ] Accident Homicide Suicide Undetermined [ Pending
Circumstances Investigation
. . . ................... ......... . :::.. ...................::.... ... ......: ..................................................... .....:::.::
Medical Certifier Name Title
p B. Peter Jensen, M.D.
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Address
6225 Main Street Argyle, NY 12809
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.. 9
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Death Certificate Filed District Number Register Number
City,Town or Village Town of Argyle 5750
11
Date Cemetery or Crematory
❑Burial 4/12/93 Pineview Crematory
......
9Cremation
Address _:::.
Queensbury, NY
Z Date Place Removed
0 E] Removal and/or Held
F-` and/or Hold ...... ....*............... ... . .....::......
Address
0................................. : .......:..............
cL Date Point of
to []Transportation by: Shipment
Common Carrier
Destination
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❑ Disinterment Date Cemetery Address
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El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm Robert M. King Funeral Home 01073
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Address
23 Church Street Granville, NY
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Name of Funeral Firm Making Disposition or to Whom
:2 Remains are Shipped, R Other than Above
_.............................................................................................. ... ......... ......... ........ .... _....... . ....
ar Address
W>
''.
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Permission is hereby granted to dispose of the hum remains described above as indicated.
Date Issued 4/10/9 3 Registrar of Vital Statistics
(signature)
District Number 5750 Place Town of Argyle, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z, Date of Disposition — Place of Disposition / /
M (address)
W
cc (section) (lot number) (grave number)
o �,04, v Y17 �� ZT 7t94/p' Name of Sexton or Person i Charge of Premises
Z (please print)
ut Signature � Title
DOH-1555 (10/89) p. 1 of 2 VS-61