MacLeod, Robert NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Robert P. MacLeod Male
Date of Death Age If Veteran of U.S.Armed Forces,
Apr 30 , 1991 8 6 War or Dates No
2 Place of Death Hospital, Institution or
l City,Town or Village Lake Placid Street Address Uihlein Mercy Center
G Mariner of Death......::.......... ridetermiried::............Pending. __.......
�X Natural Cause ❑ Accident ❑ Homicide ❑ Suicide El
Circumstances Investigation
W Medical Certifier Name Title
c H D Wilson, MD
Address
Uihlein Mercy Center, Lake Placid
Death Certificate Filed District Number Register Number
City,Town or Village Lake Placid 1560
Date Cemetery or Crematory
❑Burial 3,_:...1.991.:.... .. Pine View Cremato.r.y.....::::. .
...May..
INCremation Address
Glens Falls, N. Y .
Z Date Place Removed
0 ❑ Removal and/or Held
F—'' and/or Hold
Address
Q. Date Point of
N> ❑Transportation by Shipment
a Common Carrier .....:..
Destination
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm M B Clark, Inc . 00371
Address
27 Saranac Ave . , Lake Placid, N. Y .
. ..............
1;. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Addrla
ess
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued May 1 , 1991 Registrar of Vital Statistics 1 PLC L6 . V__C t"ti. L
(signature)
.: District Number 1560 Place Lake Placid
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I— f f
Z: Date of Disposition �"9� Place of Disposition / f1/v,E �/ le ! e,9E/fp9/Ug/el/I/I
2, (address)
w
CC (section) (lot number) (grave number)
g E241�/! p Al,9 777,94,
p' Name of Sexton Person i harge of Pre 'ses .
Z (please print) 1
W Signature Title £iPA'-7/1",9/D , 95 / /i
DOH-1555 (10/89) p. 1 of 2 VS-61