Horner, Sara s 5-?6
NEW YORK STATE DEPARTMENT OF HEALTH 4
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Sara E. Horner PPMA 1 A
Date of Death Age If Veteran of U.S. Armed Forces,
12/24/06 91 War or Dates
-.. Place of Death Hospital, Institution or
City, Town or Village Lace Placid Street Address fJihlein Mercy Center
ilk Manner of DeathLij"Natural Cause 0 Accident 0 Homicide 0 Suicide El Undetermined El Pending
twil
Circumstances Investigation
id Medical Certifier Name Title
C3 Noci Deda , MD
Address
Uihlein Mercy Center, Lake Placid, MY 1 2946
Death Certificate Filed District Number Register Number
City, Town or Village Lake Placid 1560
' > ❑Burial Date Cemetery or Crematory]
Entombment] 1?/2h/06 Pine View Crematory
Address
DCremation Glens Falls NY
Date Place Removed
2 Z Removal (and/or Held
❑and/or
F Address
l%t
Hold
0 Date Point of
E1 Transportation�}.❑ p • Shipment
Q by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Clark, Inc. 01146
Address 2310 Saranac Ave. , Lake Placid, NY 12946
Name of Funeral Firm Making Disposition or to Whom
1 - Remains are Shipped, If Other than Above
Address
IX
lti
fl Permission is hereby granted to dispose of the human remains described above a indicated.
Date Issued 12/2 6/0 6 Registrar of Vital Statistics Z on t cv �', at 1.1 L
(signature)
District Number 1560 Place Lase Placid (North Elba) , NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
UIDate of Disposition I a/,Iss lGt Place of Disposition ?,nr vi c w C`rem,d c,f i p,,,
14.1
(address)
tfl
te (section) -1 (lot number) (grave number)
fl Name of Sexton or Person in Charge of Premises ( h r,S ett tr
1z ^ (please print)
Si nature
9 �/4,14,1 Title C re""''l''r
(over)
DOH-1555 (02/2004)