Ash, Lynn v i i
NEW YORK STATE DEPARTMENT OF HEALTH '=
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lynn Ruth Ash Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 9,2013 71 War or Dates
F. Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
• Manner of Death J Natural Cause Accident 0 Homicide 0 Suicide n Undetermined n Pending
Circumstances Investigation
iu Medical Certifier Name Title
G Michael Fuller
Address
100 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 r'7/
❑Burial Date Cemetery or Crematory
❑Entombment November 12,2013 Pine View Crematorium
Address
®Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z 0 Removal and/or Held
and/or Address
�' Hold
O Date Point of
• Transportation Shipment
p by Common Destination
Carrier
pi Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped, If Other than Above
X Address
re
Permission is hereby granted to dispose of the human remains described above as 'indicated.
Date Issued l ( I /2 j/3 Registrar of Vital Statistics fit)CJ - -U
(signature)
District Number 5601 Place Glens Falls /4 y
I certify that the remains of the decedent identified above were disposed of in
accordance with this permit on:
Date of DispositionI( /3J13 Place of Disposition C {org
(address)
OC (section) pot nump�) (grave number)
p 2 Name of Sexton or Person i Charge of Premises ,,;ttPfr JQiL
WI (piease print)
Signature L �- Title eflCeMZUi'
(over)
DOH-1555(02/2004)