Stucklen, Lynn e 3
is 4 (igg
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
- Name First Middle Last Sex
L nn F.Stucklen Female
Date of Death Age If Veteran of U.S. Armed Forces,
ti 06/22/2017 62 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Granville Village Street Address Indian River Rehabilitation And Nursing Center
Manner of Death 0 Natural Cause El Accident 0 Homicide 0 Suicide ri Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
' Scott Biasetti MD
Address
A ', 100 Park St,Glens Falls,New York 12803
_-' Death Certificate Filed District Number Register Number
rfi City, Town or Village Granville Village 5725 14
DBurial Date Cemetery or Crematory
06/26/2017 Pine View Crematory
602❑Entombment Address
rdt?®Cremation Queensbury Town, New York
Date Place Removed
::: ❑Removal
and/or Held
and/or Address
Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier _
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
PIL Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
r Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/23/2017 Registrar of Vital Statistics Widrar(9Zgberts 'E&tronica[(ySigned'
(signature)
District Number 5725 Place Granville Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 6(lb Place of Disposition cot jw ifc�s,ctfotit"..,
(address)
(section) /"(�(lot number) e., (grave number)
Name of Sexton or Person i Charge of Pr ises 1('Ie;srr 11111/4/
_:,� (ple a print)
-.11 Signature Title cum�at
(over)
DOH-1555(02/2004)