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Dyslin, George NEW YORK STATE DEPARTMENT OF HEALTH lx • # ��6 Vital Records Section Burial - Transit Permit Name First Middle Last Sex George Edward Dyslin Male Date of Death Age If Veteran of U.S. Armed Forces, December 6,2012 95 War or Dates WWII �.. Place of Death Hospital, Institution or Z City, Town or Village Harrietstown Street Address Adirondack Medical Center p Manner of Death n Natural Cause X Accident 1 Homicide Suicide n Undetermined [ I Pending Circumstances Investigation W Medical Certifier Name Title G Jay S.Federman M.D. Address AMC-Saranac Lake,State Rt.86,Saranac Lake,NY 12983 _ Death Certificate Filed District Number Register NAimber City, Town or Village Harrietstown 1663 31 ❑Burial Date Cemetery or Crematory ❑Entombment December 10,2012 Pine View Crematory Address ©Cremation 21 Quaker Rd., Queensbury,NY 12804 Date Place Removed ZZ I !Removal and/or Held and/or Address N Hold co 00 Date Point of 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 I— Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains descri d above as indicated. Date Issued 12-07-2012 Registrar of Vital Statistics (signature) District Number 1663 Place Town of Harrietstown �/!//,�� D,t iZ,e v1ge /4/Q I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ILI Date of Disposition 17.-il-i1 Place of Disposition . ,,,,, 4 ayvvipftvv- 2 (address) N (section) A (lot number) ,,— (grave number) Z Name of Sexton or Person in Charge of Premises ,r,s (pie se print) W Signature _ Title CfkEEJi P-k-O(ti (over) DOH-1555(02/2004)