Lizotte, John Neil Sr � g r 9
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NEW YORK STATE DEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
John Neil Lizotte Sr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/12/2022 56 Years Waror Dates
1_, Place of Death Hospital,Institution or
ZW City,Town or Village Glens Falls Street Address Glens Falls Hospital
G Mannerof Death El Natural Cause Accident ❑Homicide Suicide Undetermined ❑Pending
IliCircumstances Investigation
W Medical Certifier Name Title
G Matthew Loftus PA
Address
100 Park St,Glens Falls,New York 12801
DeaAth Certificate Filed y Of Glens Falls District Number Register Number
City,Town or Village 5601 520
Burial Date Cemetery,Crematory or Facility Name
10/14/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
To
Removal Date Place Removed
and/or and/or Held
NHold Address
0
G. Date Point of
N Of ransportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
IDReinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped,If Other than Above
2 Address
CC
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/13/2022 Registrarof Vital Statistics Mayan Nan e ' ic�'sfl'ssa9
(signature/
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this perniton:
6 Date of Disposition i&JISI 72 Place of Disposition 6............
LLI (address/
W
CC (section/ j (lot number) (grow number)
0 Name of Sexton or Person in Charge of P miles L it
Z / (pleprint)
W Signature - Title ����
DOH-t555(o7/18)pi of 2
. 'J1_6?27
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#