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Gillingham, Lynn NEW YORK STATE DEPARTMENT OF HEALTH 11 C1t3 Vital Records Section E , Burial - Transit Permit W 3 Name First Middle Last Sex < Lynn P. Gillingham Female t Date of Death Age ' If Veteran of U.S. Armed Forces, 11/25/2017 62 , War or Dates Place of Death Hospital, Institution or /203.R'f'i S�,h��r AAtila it City,Town or Village Schroon Lake Street Address Deceased's Residence Manner of Death Natural Cause El Accident 0 Homicide 0 Suicide 1-1 Undetermined Pending Circumstances Investigation F Medical Certifier Name /i Title Sarah Thompson, i Address 24 Fairfield Ave P.O. Box 292 Sehroon Lake, NY 12870 Deat. R,. ' -te Filed J District Register tuber City Tow. •r Village,3 fO c / rj Date or r matoryv3 /� 4.y, �' 0 Burial f1 11/28/2017 0 Entombment ' " p 0 ]Cremation Address (; L1c <A4 ( -ubv(7v.,- / ' i?.?reii, 3 Date Place Removed Removal and/or Held and/or Address Hold l'i'' Date Point of ❑Transportation Shipment r : by Common Destination <, Carrier 0 Disinterment Date Cemetery Address It ��a Reinterment Date Cemetery Address * d Permit Issued to Registration Number Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141 Vr Address 9 Pine St 1 P.O. Box 455 Chestertown NY 12817 i, F' Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address 1 : ! 1,4 ',4v4 Permission is her by ranted to dispose of the human re ins described a •ve as indicated. 1,n4 x a, Date issued ii Registrar of Vital Statistics 4�l_c e,4 1 va,t.isL / (signature) �4 District Number / � Place ~~��� ! ©± eig ,? I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition )J/3Q in Place of Disposition 4'"s 'i-d -i-w (address) ! (section) (lot number) C (grave number) Name of Sexton or Person in Charge of Pr miser t zn4 (pi ase print) 4 ,„,,.: Signature a Title r�0 1 (over) DOH-1555(02/2004)