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Stark, Elaine NEW YORK STATE DEPARTMENT OF HEALTI ! S Vital Records Section Burial - Transit Permit gl Name First Middle Last Sex Elaine L._ Stark Female Date of Death Age If Veteran of U.S. Armed Forces, � ii < Feb. 22, 2018 87 yrs. War or Dates n/a Place of Death Hospital, Institution or 5 City, Town or Village Fort Ann Street Address 10492 State Rte. 149 Manner of Death©Natural Cause ❑Accident Homicide 0 Suicide Undetermined Pending Circumstances Investigation Medical Certifier Name Title Suzanne Blood MD. Address 161 Carey Rd. , Queensbury, NY. 12804 Death Certificate Filed District Number Register umber IIICity ow. .r Village �r alt ?- . 6 2 5 y , Date Cemetery or Crematory El Burial Feb. 23, 2018 PineView Crematorium Address Cremation Queensbury, NY- 12804 Date Place Removed 0❑Removal and/or Held and/or Address 11 11 Hold 0 Date Point of ai❑Transportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date ' Cemetery Address iiiiiil Permit Issued to Registration Number Name of Funeral Home /1, y 26.1�,t,,e,/ `{1,--), ,u1 D 'II 7 Address J, ,11.- J ,d g) ily� A-eL Qom.-)-� .''-z1 / a 2 Name of Funeral F Making Disposition or to�IVhom. Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described abov s ywicated. gg l Date Issued Feb. 22, 2(k'�agistrar of Vital Statistics `IIIA/�, U /�yz_2 (sign ure) District Number' 7-V Place yL-y/ t/). i} .�17 7 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: iF E Date of Disposition =-!13hht Place of Disposition 'I�v Kg....., (41.'416t'-.. a (address) LU Cl) cc (section) ,,,,Clot,numbert-- (grave number) 0Name of Sexton or Person in Charge of Premises ,)z t!tl g // a (please print) >4 Signature G�1 /4— Title /Itffin in (over) DOH-1555 (9/98)