Lent, Ethel M 7.1.1.1(\
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Ethel M Lent Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/08/2022 73 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Lake Luzeme Town Street Address 10 Beach Drive,Lake Luzeme Town,New York 12846
0 Manner of Death 1=1NaturalCause IllAccident 1:1Homicide Suicide nUndetermined ri Pending
W Circumstances Investigation
V W Medical Certifier Name Title
0 Kathy Herren PA
Address
315 S Manning Blvd,Albany,New York 12208
Death Certificate Filed Town Of Lake Luzeme District Number Register Number
City,Town or Village 5656 23
HBurial Date Cemetery,Crematory or Facility Name
09/09/2022 Pineview Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Removal Date Place Removed
and/or and/or Held
I-
- Hold Address
)
0
O. Date Point of
t/)❑Transportation Shipment
p by Common
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
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
a Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/09/2022 Registrar of Vital Statistics Cynthia Sherwood(Electronically Signed)
(signature)
District Number 5656 Place Town Of Lake Luzeme
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F-
Z Date of Disposition 9//��WZt.Place of Disposition -P,ry j6% t e) C_-1`Gm si
W (address)
W
CC (section) (lot number) (grave number)
CC
0 Name of Sexton or Person in Charge f Premiss 71�11�inao'b 00-1
Z // ` (please print)
W Si nature 6� Title t��d"k"¢6"r
g !l
DOH-1555(07/18)p 1 of 2
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#_