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Whitney, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH i 11 J I Vital Records Section Burial - Transit Permit Name First Middle Last Sex DOROTHY M. WHITNEY FEMALE Date of Death Age If Veteran of U.S. Armed Forces, OCT. 13, 2011 87 War or Dates -i! Place of Death Hospital, Institution or --6ir Town,gr�{tiiee HARRIETSTOWNlit Street Address ADRK. MEDICAL CENTER 0 Manner of Death©Natural Cause 11 Accident ID Homicide 0 Suicide 0 Undetermined 0 Pending WIn Circumstances Investigation Medical Certifier Name Title FRAMK �7- Ti()(�TT T Ar A MD Address ADRK. MEDICAL CENTER, SARANAC LAKE, NY Death Certificate Filed District Number Register Number 'iriy4 , Towne HARRIETSTOWN 1663 08urial Date Cemetery or Crematory OCT. 14, 2011 PINE VIEW CREMATORY :: 0 Entombment Address ®Cremation GLENS FALLS, NY Date Place Removed ❑Removal and/or Held and/or �;,; Address Hold CC O Date Point of ti 0 Transportation Shipment et by Common Destination Carrier Q Disinterment Date Cemetery Address i Q Renterment Date Cemetery Address !: Permit Issued to Registration Number Name of Funeral Home M. B. CLARK, INC. 01094 Address 2310 SARANAC AVE. , LAKE PLACID, NY Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above X Address ilr tip Permission is hereby granted to dispose of the human rem • described above as_i ndicated. Ai Date Issued 10/14/11 Registrar of Vital Statistics (signatur District Number1663 Place Village of Saranac Lake I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: k Li/ Date of Disposition to.-u-,oil Place of Disposition ?rye yt,'ew f.P <yrie r,:\)vi l 2 (address) ILfI ta Its (section)i i*0 lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises a`uf'te � 2 —�� (please print) Signature &41 Title Cremcdort c11 1 • (over) DOH-1555 (02/2004)