Higgins, Patricia NEW YORK STATE DEPARTMENT OF HEALTH #tf
Vital Records Section Burial - Tran it Permit
Name First Middle Last Sek
1)4i2/CM /�. //f(r r..ZNS ftHACE
Date of Death Age If Veteran of U.S. Armed Forces,
s, War or Dates .fV//c)
14 Place of Death Hospital, Institution or4uhrv/dpsC/l Mt'il/eAc C1-'-
W Ci To or Village/, , , a 57U�,,J,t Street Addres$/qjZQ,Lm ( LA/cc— , my,
WManner of Death[' Natural Cause Accident n Homicide n Suicide Undetermined ❑Pending
U — Circumstances Investigation
W Medical Certifier Name Title
Address
/4)16/t , ,r 1 eL2,c 3 .. cm. /L %s< .J A,-4/JA L, LA& ivy /rz.li ii
Death Certificate Filed District Number Register Number
City, Taw or VillageA0,2./z,,:7if R .J&J `663 40
i_i ❑Burial Date ,., Cemetery or Crematory
£.JG /3 / f/A k I .W e L€-/-z /,1 ry 47
,ii;.i, ❑Entombment Address
ACremation -?I 61, )4 , it, LO, c,/Q�>nfift/c,4 Ay /�:�C '/
Date Place Remove
ZI I Removal and/or Held
and/or Address
4,• Hold
in
C.. Date 1 Point of
Nn Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to `� Registration Number
Name of Funeral Home mg.ezk k,/,(iC . Q/O 7.5�
Address
ZO 23'v ArtAtille. ,our ZAic" /661c ;./vy //5't
Name of Funeral Firm Making Disposition or to Whom
.ii Remains are Shipped, If Other than Above
g Address
ir
U!
`. Permission is hereby granted to dispose of the human rem ins described ahoy .as indicated.
iqi Date Issued/a -//l /o2„ Registrar of Vital Statistics _40_4,
(sig re)
District Number// 3 Place Village of Saranac Lake
I` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ill Date of Disposition Place of Disposition /J1/4 y/,y 04140 40
(address)
tli
it (section) 1.- �(lot number)/ (grave number)
Name of Sexton .%Pers• in Cr/ of Premises ��`�!/ / Oat)//11�
Z // (please print)
Signature .i/� _/1 r� d Title �ryo n-j
AS-
(over)
DOH-1555 (02/2004)