Lynch, John NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
y`.v John J. Lynch Male
<''. Date of Death Age If Veteran of U.S. Armed Forces,
pi September 11, 2017 81 War or Dates n/a
r` Place of Death Hospital, Institution or
City, Town or Village Town of Queensbury,NY Street Address 70 Bay Parkway
Manner of Death Natural Cause Accident E Homicide n Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Jeffrey Perkins DO
} Address
1440 Western Ave.,Albany,NY 12203
Death Certificate Filed wn Di t Nui )er Register umber
40 City, Town or Village of Queensbury, NY l� � i
❑Burial Date Cemetery or Crematory
September 13, 2017 Pine View Crematorium
❑Entombment Address
Ei Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z 1-1 Removal and/or Held
and/or Address
H Hold
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O Date Point of
yU Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
11 Reinterment Date Cemetery Address
1 Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
:< 407 Bay Road, Queensbury, NY 12804
ta
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
0:,:.r. Permission is hereby granted to dispose of the human remains described abbvvg�ass indicated.
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�' ;� Date Issued � I 31� 1 1 Registrar of Vital Statistics ( >C^� if (L�--�
r
, _,;, (signature)
District NumbecL_c Place 1 0 C L Q Q4-)
I certify that the remains of the decedent identified above were disposed of in a orda ce with this permit on:
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�
Date of Disposition 7113117 Place of Disposition to '<... e,...4or-.i
W (address)
co
cc
g (section) A aot number) �the.��, (grave number)
Q Name of Sexton or Person in Charge of Pr mises
IZ (pl ase print)
Signature Title l{%.t J1ti tom_
(over)
DOH-1555(02/2004)