Lanphear, Glen B :: 1 4 qg
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Glen B.Lanphear Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/24/2022 69 Years War or Dates
p,,. Place of Death Hospital,Institution or
WCity,Town or Village Indian Lake Town Street Address 126 Brookside Lane, Indian Lake Town, New York 12842
0 Manner of Death jNaturalCause Accident Homicide Suicide Undetermined ❑Pending
W Circumstances Investigation
E Medical Certifier Name Title
Christopher Mason DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Indian Lake District Number Register Number
City,Town or Village 2053 5
Burial Date Cemetery,Crematory or Facility Name
,' 05/25/2022 Pine View Crematory
Entombment
— Address
IICremation Queensbury Town,New York
Donation
Z Date Place Removed
0 Removal
and/or and/or Held
F= Hold Address
Ca
A. Date Point of
FA Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
•
Date Cemetery Address
❑Reinterment
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
1.. Remains are Shipped,If Other than Above
'"s Address
Q
III
.a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/25/2022 Registrar of Vital Statistics Julie A Clawson(Electronically Signed)
(signature)
District Number 2053 Place Town Of Indian Lake
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:��//
W Date of Disposition S IM 7i Place of Disposition ,
IL 4-0-
2 (address)
W
CO
CC (section) (lot number)1 (grave number)
$' Name of Sexton or Person in Charge of Pr miles W L.. ` n
(pl se print)
Signature Title
DOH-1555(07/18)p 1 of 2
} I 7".e �
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#