Norton, Lucas R LF 11 27c
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Lucas R Norton Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/27/2022 13 Years War or Dates
F Place of Death Hospital,Institution or
W City,Town or Village Gloversville Street Address Nathan Littauer Hospital
O Manner of Death [ ]Natural Cause IllAccident El Homicide ZSuicide Undetermined ❑Pending
LIJ
0 Circumstances Investigation
W Medical Certifier Name Title
0 Sherry Brown Coroner
Address
223 W.Main St.,Johnstown,New York 12095
Death Certificate Filed City Of Gloversville District Number Register Number
City,Town or Village 1701 82
HBurial Date Cemetery,Crematory or Facility Name
03/30/2022 Plneview Crematory
Entombment Addres
Cremation Queensbury Town,New York
Donation
g I J Removal Date Place Removed
and/or and/or Held
H Hold Address
CD
0
d Date Point of
t!)❑Transportation Shipment
p by Common.
Carrier Destination
Date Cemetery Address
Disinterment
n Date Cemetery Address
I I Reinterment
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
2 Address
Q
W
C' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/29/2022 Registrar of Vital Statistics Devon Davis(Electronically Signed)
/signature)
District Number 1701 Place City Of Gloversville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z „ � �...�Fa---
W Date of Disposition ,3130 1ZZ Place of Disposition � A.0
2 (address)
W
Cl)CC (section) (jot number) (grave number)
gName of Sexton or Person in Charge Premises �h M �^' `41Ir
Z / /P!e se print/ /�jy�,��y
W . Title " Vi" "i�f/1if
Signature
DOH-1555(07/18)p 1 of 2
L-` cj
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#