VanNess, Lisa E NEW YORK STATE DEPARTMENT OF HEALTH .j Burial - Transit Per It
Bureau of Vital Records
Name First Middle Last Sex
Lisa E.VanNess Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/29/2022 58 Years War or Dates
i_ Place of Death Hospital,Institution or
W City,Town or Village Albany Street Address Albany Medical Center Hospital
p Manner of Death El Natural Cause Accident []Homicide []Suicide Undetermined []Pending
W Circumstances ' 'Investigation
U
W Medical Certifier Name Title
Ci Adrian Waisman malaret MD
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed City Of Albany District Number Register Number
City,Town or Village 0101 2789
HBurial Date Cemetery,Crematory or Facility Name
11/30/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town, New York
[]Donation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
EL Date Point of
M❑Transportation Shipment
p by Common
Carrier Destination
oDisinterment Date Cemetery Address
Date Cemetery Address
[]Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street, P.O.Box 67, Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
5 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/30/2022 Registrar of Vital Statistics 'Danie(CeS Gillespie(Electronically Signed)
(signature)
District Number 0101 Place City Of Albany
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H ,__.,
Z Date of Disposition Man(Z Z Place of Disposition ��L titi---.
(address)
W
CC N (section) A
,-(loft numbe/�/,'��'h /grave number/
0Name of Sexton or Person in Charge of Premises T
rp
lease print)
W Signature Title At 1Zi1I '
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# -'