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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permft
Bureau of Vital Records
Name First Middle Last Sex
Patrick James Lynch Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/20/2022 58 Years War or Dates
., Place of Death Hospital,Institution or
Z City,Town or Village Bolton Town Street Address 30 Heritage Village Road,Bolton Town, New York 12814
p Manner of Death O Natural Cause Accident ❑Homicide ESuicide FlUndetermined Pending
W
U Circumstances Investigation
W Medical Certifier Name Title
a Lynn Keil PA
Address
1340 State Route 9,Lake George Town,New York 12845
Death Certificate Filed Town Of Bolton District Number Register Number
City,Town or Village 5650 9
Burial Date Cemetery,Crematory or Facility Name
10/24/2022
Address Pine View Crematory
Entombment
DCremation Queensbury Town,New York
Donation
oz❑Removal Date Place Removed
and/or and/or Held
pCD
Address
0
CL Date Point of
W Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
LI
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
2 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/24/2022 Registrar of Vital Statistics Jodi cPetteys(ECectronicallySigned)
(signature)
District Number 5650 Place Town Of Bolton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:I—
W Date of Disposition /0I15(1Z Place of Disposition i r LLB Zia
address)
W
CC (section) 4,, (lot number) (grave number)
O Name of Sexton or Person in Ch of Premises
lease print/ �,y�
W Signature Title ���'�ql�'�
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) `
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#