Clark, Anna NEW YORK STATE DEPARTMENT OF HEALTH - • 1 4 i S
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
ANNA KATHREN CLARK FEMALE
Date of Death Age If Veteran of U.S. Armed Forces,
APRIL 3, 2012 95 War or Dates
}- Place of Death Hospital, Institution or
iliZ--C4y, Town GFAAftage NORTH ELBA Street Address AMC tJIHLEIN MERCY CENTER
0 Manner of Death iii7 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
Ul Circumstances Investigation
iii Medical Certifier Name Title
0 MIKHAIL GRABOVETSKY, MD
Address
AMC [JIHLEIN MERCY CENTER, LAKE PLACID, NY ARglii
Death Certificate Filed District Number Register Number
City, Town er-Vtlage NORTH ELBA 1 56 0
❑Burial Date Cemetery or Crematory
04/10/12 PINE VIEW CREMATORY
['Entombment Address
®Cremation GLENS FALLS, NY /-3 1Cl?
Date Place Removed
Z Removal and/or Held
t2❑and/or Address F;
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Hold
Date Point of
tt 0 Transportation Shipment
i3 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
I. 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
1 Remains are Shipped, If Other than Above
Address
ir
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` Permission is hereby granted to dispose of the human rem ' s described above as indicated.
1
Date Issued 0 4/1 0/12 Registrar of Vital Statistics eau l iiL[3-7,( 2�
(sign ture)
Ni District Number 1663 Place TOWN OF NORTH ELBA
lf-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 9 /li (IL Place of Disposition g,•eUkv Crtrfe Ottw,
(address)
Ili
VI
CC (section) (lot number) (grave number)
Q
CI Name of Sexton or Person in Charg of Premises S"ilt
Z, (please print)
Signature 4:07pk_ Title �QrzhiONl� k
V (over)
DOH-1555 (02/2004)