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Lyman, Jean i3D1 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jean Lyman Female Date of Death Age If Veteran of U.S.Armed Forces, 12/19/2020 68 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Schenectady Street Address Ellis Hospital 'p Manner of Death © Natural Cause ❑Accident Homicide Suicide Undetermined ❑Pending UCircumstances Investigation W Medical Certifier Name Title CI Saeed Khan MD Address 1101 Nott St,Schenectady,New York 12308 Death Certificate Filed District Number Register Number City,Town or Village Schenectady 4601 1117 ❑Burial Date Cemetery,Crematory or Facility Name 12/22/2020 Pine View Crematory Entombment Address ElCremation Queensbury Town,New York ❑Donation Z ❑Removal Date Place Removed and/or and/or Held N Hold Address 0 Date Point of (/) ❑Transportation ES Common Shipment Carrier Destination El Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Miller Funeral Home 01199 Address 6357 Nys Rte#30, Indian Lake,New York 12842 Name of Funeral Firm Making Disposition or to Whom F— Remains are Shipped,If Other than Above 2 Address Q W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/22/2020 Registrar of Vital Statistics Samanta R. Mykoo(Electronically Signed) /signature/ District Number 4601 Place Schenectady, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition f Z•ZZ•-Zi:. Place of Disposition e_0;i c f 414 cz i74/ (a ress) W CC N (section) r. (lot number) (grave number) G Name of Sexton or Person i har a of Premises IA)` � �' (please print) W Signature Title C-r-t l �/ e DOH-1555(07/18)p 1 of Public Health Law Sec. 4145(2b) - -- 01.4 319 Receipt Human remains of delivered on , 20 1 , Pine View Cemetery Representing the funeral home named on burial permit ; Official Funeral Directors Reg.or License#