Irvin, Colleen ,2,
NEW YORK STATE DEPARTMENT OF HEALTH 3 Vital Records Section Burial _ Transit Permit
Name First Middle Last Sex
Colleen Ann Irvin Female
Date of Death Age i If Veteran of U.S.Armed Forces,
November.28,2012 81 War or Dates
F_ Place of Death Hospital, Institution or
Z City,Town or Village Harrietstown Street Address Adirondack Medical Center
W Manner of Death i 1 Natural Cause C Accident [Homicide E Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
G Frank Nocilla M.D.
Address
Adk.Medical Ctr.,Rt.86,Saranac Lake,NY 12983
Death Certificate Filed I District Number Register Number
City,Town or Village Town of Harrietstown 1663 3'C
❑Burial Date Cemetery or Crematory
CI Entombment November 30,2012 Pine View Crematory
Address
®Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date I Place Removed
Z
n Removal I and/or Held
2 and/or Address
H Hold
N
0 Date Point of
N n Transportation 1 Shipment
p by Common Destination
Carrier
I Disinterment Date Cemetery Address
n 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
I- Remains are Shipped, If Other than Above
2 Address
tZ
W
a. Permission is hereby granted to dispose of the human remains described ove as indicated.
Date Issued 11-20-2012 Registrar of Vital Statistics l' V�` AP�
(signature)
District Number 1663 Place Town of Harrietstown
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z� Date of Disposition j`�ct�-/Z— Place VI/�Place of Disposition N r�/ C -✓,}-';�?'�-
1
W (address)
Cl)
n' (section) t number) (grave number)
O
p Name of Sexton r Pe son in C ge of Premises () f f ,"/ t-c
Z (please print)
W
Signature Title ( � S
(over)
DOH-1555(02/2004)