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Preston, Mark NEW YORK STATE DEPARTMENT OF HALTki♦ 3 �U Vital Records Section Burial - Transit ermit Name First Middle Last Sex _ MARK ALLEN PRESTON MALE Date of Death Age If Veteran of U.S. Armed Forces, J tJLY 30, 2011 51 51 War or Dates Place of Death Hospital, Institution or NORTH ELBA City, Town or Villageitit Street Address AMC © LAKE PLACID c Manner of Death ©Natural Cause 0 Accident 0 Homicide ❑Suicide riUndetermined Pending Circumstances Investigation U Medical Certifier Name Title 44 C. PRANCTS VARGA, MD Address 303 LAKE PLACID CLUB WAY LAKE PLACID, NY 12946 Death Certificate Filed District Number Register Number '': City, Town or Village NORTH ELBA 1560 1 LIBurial Date Cemetery or Crematory AUG. 1 , 2011 PINE VIEW CREMATORY Entombment Address ®Cremation GLENS FALLS, NY Date Place Removed Removal and/or Held and/or Address F= Hold till 0 Date Point of ❑Transportation Shipment Q by Common Destination Carrier 0 Disinterment Date Cemetery Address 0 Reinterment Date Cemetery Address i. Permit Issued to Registration Number Name of Funeral Homii• B. CLARK, INC. 01094 Address 2310 SARANAC AVE. , LAKE PLACID, NY 12946 Name of Funeral Firm Making Disposition or to Whom I.- Remains are Shipped, If Other than Above a. Address CC to Permission is hereby granted to dispose of the human re a ns described above as indicated. Date Issued AUG. 1 , 2011Registrar of Vital Statistics f- jt�,l.� j// ( i t ,,i)<,d!(signa{ure) District Number 1560 Place �,,,,A./ or e / ±u3/9 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Ul Date of Disposition %-Z-p Place of Disposition -PINOtt.%) A-1/4 2 (address) Ui C (section) (lot number) (grave number) Name of Sexton or Person in Charge of remises riSICuii4 r �-please print) t Signature //�� Title CREn (Tv+L (over) DOH-1555 (02/2004)