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Somberg, Joan -11 NEW YORK STATE DEPARTMENT OF HEALTH "t51 Vital Records Section . f + ,� Burial - Transit Permit Name First Middle Last Sex JOAN ELIZABETH SOMBERG FEMALE Vii Date of Death Age If Veteran of U.S. Armed Forces, AUG. 29, 2011 79 War or Dates • Place of Death Hospital, Institution or LAKE PLACID, NY 7 -City , Town ore NORTH ELBA Street Address SUMMER RESIDENCE EAST LAKE at Manner of Death©Natural Cause 0 Accident El Homicide 0 Suicide Undetermined �Pending Li) Circumstances Investigation Medical Certifier Name Title O C. FRANCIS VARGA, MD Address P. 0. BOX 768 LAKE PLACID, NY 12946 Death Certificate Filed District Number Register Number Town or NORTH ELBA 1560 ❑Burial Date Cemetery or Crematory 09/01/2011 PINE VIEW CREMATORY 4, ❑Entombment Address ®Cremation GLENS FALLS, NY Date Place Removed ❑Removal and/or Held and/or Address CA Hold 0 Date Point of 0 La Transportation Shipment Q by Common Destination Carrier Q Disinterment Date Cemetery Address 0 Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M. B. CLARK, INC. 01094 Address 2310 SARANAC AVE. , LAKE PLACID, NY 12946 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above g Address ir tI L Permission is hereby granted to dispose of the human remain descrK;e7,4,- bed ab ve as/ indicated. Date Issued 0 8/31/11 Registrar of Vital Statistics 44,(,�,u( C C� (signature), District Number 1560 Place 70uhv 6r e-n-i Et i 3.1 �- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 Lil Date of Disposition q le jai Place of Disposition feittJrtt.) C,fwyr' 01/(4— 2 (address) w Ct (section) (lot mber) (grave number) Name of Sexton or Per •n in Charge of remises t,s 1 �n�N tt ( nuease print) Signature C '' y ' Title OVi-fi MOQ (over) DOH-1555 (02/2004)