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Stark, Elaine NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Elaine W. Stark Female Date of Death Age If Veteran of U.S. Armed Forces, 12/10/2014 81 years _ War or Dates • Place of Death Hospital, Institution or Town orAhttax Granville Street Address The Orchard Nursing & Rehah Centre ILI 0 Manner of Death ©Natural Cause O Accident O Homicide 0 Suicide riUndetermined El Pending IL Circumstances Investigation ILI Medical Certifier Name Title Kevin Gallagher M D Address 79 North Street, Granville, N Y 12832 Death Certificate Filed District Number Register Number )(XD9XTown or)0116 1 Granville 5756 51 OBurial Date Cemetery or Crematory 12/10/2014 Pine View Crematory []Entombment Address ©Cremation Queensbury, N Y Date Place Removed Z Removal and/or Held 9?.O and/or Address : Hold O Date Point of O Transportation Shipment . by Common Destination _ Carrier Q Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number I> Name of Funeral Home Mason Funeral Home 01189 Address Po Box 277, Fort Ann, N Y Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above • Address IX iu Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/10/2014 Registrar of Vital Statistics /(,,,,of )110..4, (sig ature) District Number 5756 Place Granville fr I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Place of Disposition 'f M�.t1.. Cs-tea-✓ ILI Date of Disposition (2�IE,Iv� p (address) Ltf ffi rc (section) / (lot number) (grave number) . CIName of Sexton or Pe son in Charge of Premises /414ri- Sttw- z ((please print) JJ Signature Title eia✓W;t�-. (over) DOH-1555 (02/2004)