Glass, Alan NEW YORK STATE DEPARTMENT OF HEALTH ' ' it
Vital Records Section Burial - TransitPermit
Name First Middle Last Sex
AT,AN JAY GLASS MALE
gii Date of Death Age If Veteran of U.S. Armed Forces,
,TUT,Y 29 , 2011 75 War or Dates KOREA 1959-63
14 Place of Death Hospital, Institution or
City, Town or Village NORTH ELBA Street Address AMC-LAKE PLACID
aManner of Death® Natural Cause 0 Accident 0 Homicide 0 Suicide r7 Undetermined 0 Pending
Circumstances Investigation
la Medical Certifier Name Title
C. FRANCIS VARGA, MD
Address
330 LAKE PLACID CLUB WAY, LAKE PLACID, NY
Death Certificate Filed District Number Register Number
City, Town or Village north elba 1560
❑Burial Date Cemetery or Crematory
AUG. 1 , 2011 PINE VIEW CREMATORY
: Entombment Address
®Cremation GLENS FALLS, NY
Date Place Removed
Z ❑Removal and/or Held
2 and/or Address
t= Hold
to
0 Date Point of
Ill'.! El Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
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
2 Address
1
tli
"" Permission is hereby granted to dispose of the human re ins describedboe as indicated.
Date Issued 08/01/2011 Registrar of Vital Statistic
(signatur
ili District Number 1560 Place 70-,,vAi or eT}-/ 63,42
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition 414I It Place of Disposition gALuw C.rt,,,=1o* IA,
(address)
Ili
[A
1 (section) II (lot number) (grave number)
Q �!
Name of Sexton or Person in Charge of Premises I ht,s P- S.4Nrt
Z ease print)
ill Signature ��4 J/ Title Col e nfttkiUt.
(over)
DOH-1555 (02/2004)