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Lynch, Bartholomew ' ti $13 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit - M Name First Middle Last Sex -0Bartholomew J. Lynch Male Date of Death Age If Veteran of U.S. Armed Forces, r November 12, 2016 91 War or Dates 1979- 1985 Place of Death Hospital, Institution or r-'° City, Town or Village Queensbury Street Address Stanton Nursing& Rehab Centre �: Manner of Death n Natural Cause { Accident I !Homicide n Suicide n Undetermined n Pending 'j` Circumstances Investigation Medical Certifier Name Title Address f; Death Certificate Filed District Number Register`� umber {f.: City, Town or Village Queensbury 5657 j 1--1-1 ❑Burial Date Cemetery or Crematory ❑Entombment November 15, 2016 Pine View Crematorium Address ©Cremation 51 Quaker Road, Queensbury,NY 12804 Date Place Removed Z piRemoval and/or Held and/or Address F' Hold • Cl) 0 Date Point of O. N Transportation Shipment p by Common Destination Carrier n Disinterment Date Cemetery Address n Reinterment Date Cemetery Address ', Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address / 407 Bay Road, Queensbury, NY 12804 _ Name of Funeral Firm Making Disposition or to Whom . . Remains are Shipped, If Other than Above zf Address r Permission is hereby granted to dispose of the hum m ins d ibed v as i •icated. • Date Issued 1 1--14—UO Registrar of Vital Statistic `0 t; (sig . u • District Number 5657 Place Queensbury gg I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: iLi Date of Disposition /j Jj 7rM jj1 Place of Disposition v�c� C jof L.,2 (address) U) x (section) n,(iot number) r (grave number) p Name of Sexton or Person in Charge of Premises `/ is w JGif,f�j Z (p/base print) W Signature Title C -40C (over) DOH-1555(02/2004)