O'Rourke, Lynne NEW YORK STATE DEPARTMENT OF HEALTH ' ' n 7ir
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
LYNNE MARY O'ROURKE Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 1 , 2015 64 War or Dates n/a
14 Place of Death Hospital, Institution or
City, Town or Villagelit Glens Falls, NY Street Address Glens Falls Hospital
0 Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide 0 Undetermined 0 Pending
Circumstances Investigation
Medical Certifier Name Title
James North, MD
Address
Glens Falls, NY
Vi Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls, NY 5601
Nil❑Burial Date Cemetery or Crematory
April 3, 2015 Pine View Cemetery
i ❑Entombment Address
i!Icremation Quaker Road, Queensbury, NY
Date Place Removed
❑Removal and/or Held
and/or Address
w"` Hold
V.
O Date Point of
i;El Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date ' Cemetery Address
❑Reinterment Date - Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Staf ford Funeral Home 01443
Address
53 Quaker Rd, Queensbury, NY 12804
liiig Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ir
ILI
Permission is hereby granted to dispose of the human remains described abo e as- i ted.
iii
Date Issued 4/3/2015 Registrar of Vital Statistics .1� `
(signature)
iillillii District Number 5601 Place City of Glens Falls, NY
>..>: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
t:LI Date of Disposition 11'1 I i c Place of Disposition ,Artt.. ,r �,.,/p..-
2 (address)
ILI
CE (section) (lo•number) (grave number)
ei Name of Sexton or Person in Charge of Premises i1 n 1
++ (please rmt)
i Signature Title ZT 04f ttjyt,
(over)
DOH-1555 (02/2004)