Lacy, Eleanor -14-"te.,6
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NEW YORK STATE DEPARTMENT OF HEALTH IN`
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Eleanor M. Lacy Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 18,2014 89 War or Dates
Place of Death Hospital, Institution or
ZCity, Town or Village North Elba Street Address AMC-Uihlein Living Center +
p Manner of Death n Natural Cause I I Accident Homicide Suicide Undetermined l Pending
w Circumstances Investigation
u Medical Certifier Name Title
G Avi Hettena,M.D. M.D.
Address
185 Old Military Rd.,Lake Placid,NY 12946
Death Certificate Filed District Number Register Number
City,Town or Village Town of North Elba 1560 /D
❑Burial Date Cemetery or Crematory
Entombment March 20,2014 Pine View Crematory
Address
❑x Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z — Removal and/or Held
and/or Address
H Hold
CO
0 Date Point of
Nj Transportation Shipment
a by Common Destination
Carrier
1
Disinterment Date Cemetery Address
I
I 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
r
ILI
aPermission is hereby granted to dispose of the human rema s des ribed bove as indicated.
Date Issued 03-19-2014 Registrar of Vital Statistics _ 1 �z°
(signet e)
District Number 1560 Place Town of North Elba
I certify that the remains of the decedent identified above were disposed of in accordance with thisf_ permit on:
Date of Disposition Place of Disposition 0/YtJf_ Vc C-1 k ., i 1 6)"
2 (address)
Ill
DC (section) num r) (grave number)
Q Name of Sexton 4 Person " arge of Premises 5-co
�� d
!WSignature . 4bi Title jasePrin ,_
(over)
DOH-1555(02/2004)
-- 1 I Vhl1.It I1I 1a.TTl
a❑J ReintermentDate Cemetery Address
Permit Issued to rm� Registration Number
Name of Funeral Home Mct t�nard 'Baiter F er� Oh j 3O
Address /I Lcz a.yette a1. , &Litl.WSIDUIV ►Alex() York- J Y--1
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
`,d's
.2,
Permission is hereby granted to dispose of the humanr ains described above as- idicated.
._ Date Issued GD/1.20I(-1 Registrar of Vital Statistics tJ V
(sign re)-e-
* d
District Number Place 6-6
:.,.:
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
6 Date of Disposition itt rt Place of Disposition ,u ii,,,.. C 4;bt,%,
V (address)