Baxter, David f i (021
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
DAVID GRAHAM BAXTER MALE
Date of Death Age If Veteran of U.S. Armed Forces,
DECin . 19, 2011 55 War or Dates
-- Place of Death Hospital, Institution or
-fib'Village LAKE PLACID Street Address 24 BAXTER WAY
14 0 Manner of Death®Natural Cause Accident Homicide 0 Suicide � Undetermined Pending
t Circumstances Investigation
tu Medical Certifier Name Title
WOODS McCAHILL, MD
Address
JOHN BROWN ROAD, LAKE PLACID, NY
Death Certificate Filed District Number Register Number
-eity-TewrrerVillage LAKE PLACID 1560
❑Burial Date Cemetery or Crematory
DEC. 22, 2011 PINE VIEW CREMATORY
❑Entombment Address
`'<<®Cremation GLENS FALLS, NY
Date Place Removed
fl❑Removal and/or Held
and/or Address E;;;,;
Hold
0 Date Point of
05 Q Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
n 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
#^ Remains are Shipped, If Other than Above
2 Address
M
W
Permission is hereby granted to dispose of the human rem - des ed a'ove as indicated.
Date Issued 12/21/11 Registrar of Vital Statistics etakiitikk.'a I
(signatur
District Number 1560 Place �,,,JA/ of A6ei Elaxt
1- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
9siktik.4C .
IJJ Date of Disposition �c P3�2a+1 Place of Disposition iuti•
(address)
1.1
VI
C (section) A (lot nuer) (grave number)
aName of Sexton or Person in Char of Premises r s e.ati-
z 1r mb(please print)
Signature Title .Cp, WYrid2.
(over)
DOH-1555 (02/2004)