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Fleming, Thomas k '� NEW YORK STATE DEPARTMENT OF HEALTH 44- 5.°/0 Vital Records Section Burial - Transit Permit Name First Middle Last Sex THOMAS MICHAEL FLEMING MALE Date of Death Age If Veteran of U.S. Armed Forces, 11/2 6/2 011 25 War or Dates j+- Place of Death Hospital, Institution or Z City, Town or Village NORTH ELBA Street Address 92 NORTHwfOn ROAD 0 Manner of Death Undetermined Pending Natural Cause 0 Accident 0 Homicide ®Suicide tit 0 Circumstances Investigation ta Medical Certifier Name Title C. FRANCIS VARGA, MD Address LAKE PLACID CLUB WAY, LAKE PLACID, NY 12946 Death Certificate Filed District Number Register Number City, Town or Village NORTH ELBA 1560 ;<;; D Burial Date Cemetery or Crematory 11/30/2011 1 PINE VIEW CREMATORY ❑Entombment Address ©Cremation GLENS FALLS, NY Date Place Removed ❑Removal and/or Held and/or Address F. Hold tel O Date Point of tit' Transportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Q 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 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped, If Other than Above • Address fr ;'" Permission is hereby granted to dispose of the human remain escribed ab ve as indicated. Date Issued 1147/11 Registrar of Vital Statistics Ll ClAV--G (signature) District Number 1560 Place With./ or 2�-/ E u3N F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 30lif Cra.ct3i k•. Date of Disposition pot/ IZD��Place of Disposition Ph,40kW (address) UI 1,0 CC (section) (lot numb (grave number) CI Name of Sexton or Person in Char of Premises �(Al*r L 14. (please print) Ui Signature 410,, Title ,CgO1r1P1T,Olt- (over) DOH-1555 (02/2004)