Hadjis, Eugenia IINEW YORK STATE DEPARTMENT OF HEALTPI �O
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Eugenia Hadjis Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 30,2014 101 War or Dates
F. Place of Death Hospital, Institution or
Z City, Town or Village Lake Placid Street Address 85 Acorn Street
1Q Manner of Death 'XI Natural Cause Accident + I Homicide Suicide 1 Undetermined Pending
u1 Circumstances Investigation
uj G Medical Certifier Name Title
Josh Schwartsberg M.D.
Address
Church St.,Lake Placid,NY 12946
Death Certificate Filed District Number Register Number
City, Town or Village Village of Lake Placid 1523
❑Burial Date Cemetery or Crematory
❑Entombment May 1,2014 Pine View Crematory
Address
xD Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
E Hold
N
0 Date Point of
I "Transportation Shipment
p by Common Destination
Carrier
I
1 Disinterment Date Cemetery Address
1 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
2 Address
W
a 2
Permission is hereby granted to dispose of the human r= desc ,bed above as indicated.
Date Issued 05-01-2014 Registrar of Vital Statist s- _it,
(s gnature)
District Number 1523 Place Village of Lake Placid
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition TR IN Place of Disposition Za n„j Ct-we ,a.►A.,'
W (address)
(I)
r
(section) {lot number) (grave number)
Z Name of Sexton or Person ' Charge of Premises 4f 1 z i.4
tease print)
W
Signature Title CtO
(over)
DOH-1555(02/2004)