Lincoln, Edward NEW YORK STATE DEPARTMENT OF HEALTH -., t 4 33
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
EDWARD JAMES LINCOLN MALE
Date of Death Age If Veteran of U.S. Armed Forces,
06/24/12 75 War or Dates
ii Place of Death Hospital, Institution or
City, Town or Village HARRIETSTOWN Street Address ADRK MEDICAL CENTER
W▪ Manner of Death®Natural Cause El Accident El Homicide El Suicide 17❑Undetermined ❑Pending
Circumstances Investigation
w Medical Certifier Name Title
ASIF FAROOQI , MD
Address
ADRK MEDICAL CENTER SARANAC LAKE, NY
Death Certificate Filed District Number Register Number
City, Town or Village HARRIETST3IWN 1663 £�
❑Burial Date Cemetery or Crematory
❑Entombment 06/29/12 1 PINE VIEW CREMATORY
Address
! [ Cremation GLENS FALLS, NY a`6° 1
Date Place Removed
❑Removal and/or Held
and/or Address
'" Hold
Cl)
0 Date Point of
• ❑Transportation Shipment
G! by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to B. CLARK, INC . _Regibtrl i9%Number
Name of Funeral Home
Address ��i t I
2310 SARANAC AVE. , LAKE PLACID, NY b
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address -
te
in
9' Permission is hereby granted to dispose of the human re ins described ab ndicated.
Date Issued 0 6/2 6/12 Registrar of Vital Statistics
ignature)
District Number 166 3 Place Village of Saranac Lake )a ct tab
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 1E, Place of Disposition '(1r40(41J l,l'Wvtit 6etu1..„
2 (address)
lit )1.I7
til
>7 (section) l/ , (lot number) (grave number)
el Name of Sexton or P rson in Charge of Premises Chtiit r S[w4it
2 lease print)
41 SignatureA Title Clye in!IV)
(over)
DOH-1555 (02/2004)