Dunn, Araxie NEW YORK STATE DEPARTMENT OF HEALTH f ,
Vital Records Section Burial - Transit Permit
g. Name First Middle Last Sex
ARAXIE AZGAPETIAN DUNN FEMALE
Date of Death Age If Veteran of U.S. Armed Forces,
03/21/2012 95 War or Dates
}-! Place of Death Hospital, Institution or
Z -City;Town er +liege NORTH ELBA Street AddressAMC IJIHLEIN MERCY CENTER
Manner of Death❑X Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined ❑Pending
Circumstances Investigation
L Medical Certifier Name Title
DEBORAH MARSHALL, NP-C
Address
AMC IJIHLEIN MERCY CENTER LAKE PLACID, NY /Zg V
Death Certificate Filed District Number Register Number
-City, Town er-Vi#age NORTH ELBA 1560
❑Burial Date Cemetery or Crematory
03/22/12 PINE .VIEW CREMATORY
['Entombment Address
[Cremation GLENS FALLS, NY
Date Place Removed
Z Removal and/or Held
2 ❑and/or Address
I=
.(!?
Hold
0 Date Point of
Cti Transportation Shipment
it3 ln ❑
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. CLARK, INC. , 01076
Address
2310 SARANAC AVE. , LAKE PLACID, NY l--)G►y
Name of Funeral Firm Making Disposition or to Whom
1= Remains are Shipped, If Other than Above
Address
tr.
LU
DL
Permission is hereby granted to dispose of the human rema' descr' ed a ve as indicated.
Date Issued 0 3/2 2/1 2 Registrar of Vital Statistics Z4/ iL i 1- de.
I (signature)
District Number 1560 Place LAKE PLACID-NORTH ELBA
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 3)3-o 1.Place of Disposition (`n.e k f%'P�.,J (f P►►lea-Ai 1
(address)
11
to
1F (2ection i (lot number) (grave number)
ci Name of Se x t on or Person in Cha a of Premises Mp t ribnell
�"f lease print)
Signature �k�ry Title Cre mr�-ar�yt,4T/,
(over)
DOH-1555 (02/2004)