Southmayd, Mattie NEW YORK STATE DEPARTMENT OF HEALTII Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mattie Marie Southmayd Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 20,2015 88 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village North Elba Street Address AMC-Uihlein Living Center
pManner of Death X Natural Cause I I Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
CI Deborah Marshall NP-C „
Address
AMC-Uihlein, 185 Old Military Rd.,Lake Placid,NY 12946
Death Certificate Filed District Number Register Number
City, Town or Village Town of North Elba 1560 //
❑Burial Date Cemetery or Crematory
❑Entombment March 24,2015 Pine View Crematory
Address
❑x Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
Hold
N
0 Date Point of
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Clark,Inc. 01075
Address
2310 Saranac Ave.,Lake Placid,NY 12946
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
E Address
W
• Permission is hereby granted to dispose of the human rem s des ibed ve as indicated.
Date Issued 03-20-2015 Registrar of Vital Statistics
(signal' e)
District Number 1560 Place Town of North Elba
I certify that the remains of the decedent identified above were disposed of in accordanc with this permit on:
Date of Disposition �t'S Place of Disposition (�!/� (J fr(i 47
(address)
Er
(section) #(lot 'ber) f (grave number)
pName of Sexton ()ye '. Charge of Premises --t w GI
Z (p ease print)
W Signature Title W47./C Al-
(over)
DOH-1555(02/2004)