Lynch, Eleanor r • : . ft -Ai
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Eleanor A. L nch Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 19,2016 90 War or Dates NA
Place of Death Hospital, Institution or
rCity, Town or Village Glens Falls Street Address Glens Falls Hospital
il
;` Manner of Death g Natural Cause Accident Homicide n Suicide Undetermined n Pending
n Circumstances Investigation
. Medical Certifier Name Title
rzi Noelle Stevens
y
�' Address
f;f
100 Broad St.Glens Falls NY 12801
Death Certificate Filed District Number Register Number
%,. City, Town or Village Glens Falls, y‹)
NY � I Da5
❑Burial Date Cemetery or Crematory
❑Entombment October 21,2016 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z n Removal and/or Held
9 and/or Address
H Hold
N
O Date Point of
Nii Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
ri Reinterment Date Cemetery Address
;., Permit Issued to
�; Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
�Ilrr
407 Bay Road, Queensbury, NY 12804
'/ Name of Funeral Firm Making Disposition or to Whom
fril Remains are Shipped, If Other than Above
v
�ss
Address
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fPermission is hereby granted to dispose of the human remains described above as indicated.
fo Date Issued )0 1 2-t /20►h Registrar of Vital Statistics r , 1
6 r (signatur
District Number �j�j a Place �5 rj S, b`
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �+
LuDate of Disposition lb/zc1�, Place of Disposition c1v . -rcma'ior-�w•
Ill (address)
a)
IZ
0 (section) ` (lot number) rr (grave number)
Name of Sexton or Person in Charge of Premises �nsiv . Jttie/0
( lease print)
W Signature c.0 .14Zi Title `EfpltiVe
(over)
DOH-1555(02/2004)