Onufryk, Mary NEW YORK STATE DEPARTMENT OFISEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary M. Onufryk Female
Date of Death Age If veteran of U.S.Armed Forces,
June 2,2011 93 War or Dates
1— Place of Death Hospital, Institution or
Z City,Town or Village North Elba Street Address Adirondack Medical Center-Uihlein
W
0 Manner of Death ❑X Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W
V Medical Certifier Name Title
W Mandeep Saluja MD.
CI Address
AMC-Uihlein, 185 Old Military Rd. Lake Placid,NY. 12946
Death Certificate Filed District Number Register Number
City Town,Village North Elba 5160 /1,
Date Cemetery or Crematory
❑ Burial 6/3/2011 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensburry, NY 12804
Date Place Removed
O I Removal and/or Held
i= and/or Address
CO Hold
0 Date Point of Shipment
CL
❑Transportation
p by Common Destination
Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Director M. B. Clark, Inc. 01094
Address
2310 Saranac Avenue Lake Placid, NY 12946
Name of Funeral Firm Making Disposition or to Whom
L` Remains are Shipped, If Other than Above
2 Address
W
CL
Permission is hereby granted to dispose of the human remains describ above indica d.
Date Issued June 2,2011 Registrar of Vital Statistics 1I2714 CAA l til-ei7
(signature
District Number 5160 Place /i d fh `, /bl1
I certify that the remains of the decedent identified above were disposed of in accordance with this Krmit o
Z Date of Disposition c Ito ill Place of Disposition p mill%ems C..f+r-(tOri V
W
LLI address)
L1
1:e
1
O (section) (lot num (grave number)
Name of Sexton/0 person in Charg of Premises ` ii rt-l'� (e nevi,*
Z � r(please print)
W Signature 7 t59 Title GRjylletivit
DOH - 1555 (10/89) p. 1 OF 2 VS - 61