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Lashway, Jeffrey Kenneth � _. fi 31a NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jeffrey Kenneth Lashway Male Date of Death Age If Veteran of U.S.Armed Forces, 04/02/2023 62 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village South Glens Falls Village Street Address 61 Wilson Avenue,South Glens Falls Village,New York 12803 UJ 0 Manner of Death ❑X Natural Cause Accident El Homicide nSuicide FlUndetermined Pending V I—ICircumstances Investigation W Medical Certifier Name Title u Joseph Mihindukulasuriya MD Address 20 Murray Street,Glens Falls,New York 12801 Death Certificate Filed Village Of South Glens Falls District Number Register Number City,Town or Village 4524 7 Burial Date Cemetery,Crematory or Facility Name 04/05/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York DDonation 0 D Removal Date Place Removed and/or and/or Held N Hold Address to DTransportation Date Point of $ by Common Shipment Carrier Destination EI Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 2 Address W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/05/2023 Registrar of Vital Statistics Samantha Berg(ECectronicaltySigned) (signature) District Number 4524 Place Village Of South Glens Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition /---li jp,7,j Place of Disposition ',J e ereobriot,A UJ 2 (addres W CC (section) `` (/ num r) (grave number) gName of Sexton or Person in Charge of Premises l'Q i/1#tot i.b l l� Z jay I (please print) W Signature 4r11A / Title 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#