Lynch, John NEW YORK STATE DEPARTMENT OF HEAL`IIH ' It 611
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John Roy Lynch Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 1 1 , 201 3 66 yrs. War or Dates No
1-.: Place of Death Town of Hospital, Institution or
Heritage Commons
iTi City, Town or Village Ticonderoga Street Address Residential Healthcare
p Manner of Death u Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Ili Medical Certifier Name Title
Richard McKeever M.D.
Address
102 Race Track Road, Ticonderoga, NY 12883
Death Certificate Filed District Number Register Number
Ci , Town or Village Town of
tY 9 Ticonderoga 1564II 71
.:❑Burial Date Cemetery or Crematory
['Entombment Address
Pine View Crematory
Address
®Cremation Queensbury, NY
Date Place Removed
Removal and/or Held
O and/or Address
t Hold
CA
O Date Point of
o Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
`- Remains are Shipped, If Other than Above
• Address
tI
!" Permission is hereby granted to dispose of the human re ains described above as indicated.
iiN Date Issued 1 0/1 4/201 3 Registrar of Vital Statistics m• 61.1-t
(signature)
ig District Number 1 564 Place Town of Ticonderoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
ILI Date of Disposition f0IRA, Place of Disposition R,,D►=v r,wFa,.—
(address)
LEI
Ul
CC (section) t number) (grave number)
D Name of Sexton or Person i Charge of Premises lilt
JI 4
Z (pleas print)
• Signature Title n2E06131
(over)
DOH-1555 (02/2004)