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Gray, Edward NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex EDWARD F. GRAY MALE iiiNi Date of Death Age If Veteran of U.S. Armed Forces, iliQ NOV. 2, 2011 91 War or Dates WW 2 44: Place of Death Hospital, Institution or Z City, Town or Village HARRIETSTOWN Street Address ABRE MEDICAL CENTER Manner of Death©Natural Cause D Accident E Homicide 0 Suicide Undetermined 0 Pending tii Circumstances Investigation al Medical Certifier Name Title WLLIAM VISCARDO, MD Address ADRK MEDICAL CENTER, SARANAC LAKE, NY. Death Certificate Filed District Number Register Number City, Town or Village HARRIETSTOWN 1663 < >El Burial Date Cemetery or Crematory NOV. 3, 2011 PINE VIEW CREMATORY ' DEntombment Address ®Cremation GLENS FALLS, NY '''' Date Place Removed Removal and/or Held 91—land/or Hold Address 0 0 Date Point of Cti Q Transportation Shipment Q by Common Destination Carrier Q Disinterment Date Cemetery Address l D 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 Address re tt . Permission is hereby granted to dispose of the human remain described ab ve as indicated. Date Issued 11/3/11 Registrar of Vital Statistics A. ignature) iiiii District Number 1663 Place Village of Saranac Lake I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: lit Date of Disposition 1 j-4-go l if Place of Disposition ?I'ne_V;e'er C r-c wz 4.; car t,u key) (address) tti te 'IX (sec ) (lot number) (grave number) aName of Sexton or Person in Charge f Premises ( LW\044ty (3r0 he lie �—^+ �, (please print) 3 Signature —'"w"c Title Crewi*ct4-or`l 1055-1 . (over) DOH-1555 (02/2004)