Sanderson, Ardelle NEW YORK STATE DEPARTMENT OF HEALTH 4,
Vital Records Section t ' Burial - Transit Permit
Name First Middle Last Sex
ARDELLE V. SANDERSON FEMALE
Date of Death Age If Veteran of U.S. Armed Forces,
SEPT. 15, 2011 95 War or Dates
14, Place of Death Hospital, Institution or
City, Town or Village HARRIETSTOWN Street Address ADRK. MEDICAL CENTER
p Manner of Death Natural Cause El Accident Homicide E Suicide Undetermined El Pending
0 Circumstances Investigation
ui Medical Certifier Name Title
a FRANK JOHN NOCILLA, MD
Address
185 OLD MILITARY RD. , LAKE PLACID, NY
Death Certificate Filed District Number Register Number
City, Town or Village HARRIETSTOWN 1663
0 Burial Date Cemetery or Crematory
SEPT. , 16, 2011 PINE VIEW CREMATORY
';s❑Entombment Address
®Cremation GLENS FALLS, NY
Date Place Removed
g❑Removal and/or Held
and/or Address
t.lt Hold
U
0 Date Point of
Trans ortation Shipment
❑ P
0 by Common Destination
,i Carrier
Q Disinterment Date Cemetery Address
[�Reinterment Date Cemetery Address
Permit Issued to Registration Number
<1 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
Z Address
Lu
Permission is hereby granted to dispose of the human re a' s described abov dicated.
Date Issued 09/16/11 Registrar of Vital Statistics .f?i-r.,_
(signature)
!ii;: District Number 1663 Place s Village of Saranac Lake
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
( i u t,
I Date of Disposition ` itlIf1 Place of Disposition cYwU ku
(address)
Ili
CC (section) A , (t t number) (grave number)
0 Name of Sexton or Person in Charge of Premises cH ( L '"
( /ease print)
gl
Signature.2 AL Title CLIE.41 iO_
(over)
DOH-1555 (02/2004)