Smith, John NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
John B Smith
Date of Death Age If Veteran of U.S.Armed Forces,
1/19/93 61 WarorDates WW2
Z Place of Death Hospital, Institution or
r
uj City Town or Village Saranac Lake Street Address A_M-C...@....Saranac: LaktrCa
Manner of Death El Natural Cause Accident ❑ Homicide ElSuicide ❑ Undetermined El Pending
Circumstances Investigation
11l
Medical Certifier Name Title
p H D Wilson, M . D .
Address
Lake Placid, N. Y .
Death Certificate Filed District Number Register Number
City,Town or Village Saranac Lake 1653
Date Cemetery or Crematory
❑Burial Jan. 21 , 1993 Pine View Crematory
Cremation Address
Glens Falls, N. Y .
Z Date Place Removed
0 0 Removal and/or Held
H and/or Hold ::...
Address
Date Point of
cn ❑Transportation by Shipment
p? Common Carrier
Destination
............................................................................................................................. ............................................................................................................................................
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm M B Clark, Inc . 00367
Address
27 Saranac Ave . , Lake Placid
....................................................................................................................................................................................................................................................................................
Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
;ut<
Address
Cl.
....................................................................................................................................................................................................................................................................................
Permission is hereby granted to dispose of the human remains describ- • above as 'ndicated.
Date Issued 1/20/93 Registrar of Vital Statistics ,�pj; �. ��/
ignature)�/
District Number 1653 Place Saranac Lake (Harrietstown) , N. Y .
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition/"a9.3 Place of Disposition ,7/I/lik—1 4SC) C/P.. c 2i9/;10e iU41
2 (address)
CD
w`
CC
(section) (lot number) (grave number)
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0
/I..—'&J .l> �lil/�T//7�4)
p Name of Sexton or Person in Char e of Premises
lease print) �/�, —�-
w Signature r ems.. � Title ���4l�T/�t' i�i�J,. ! 2
DOH-1555 (10/89) p. 1 of 2 VS-61