Bruce, Jr. William i
NEW YORK STATE DEPARTMENT OF HEALTH l��
Vital Records Section _ — • Burial - Transit Permit
Name First Middle Last Sex
WILLIAM G. BRUCE, JR MALE
Date of Death Age If Veteran of U.S. Armed Forces,
MAR. 17, 2012 77 War or Dates U. S. ARMY
i-- Place of Death Hospital, Institution or
W City, Town or Village NORTH ELBA Street Address AMC-UIHLEIN MERCY CENTER
W Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide El Undetermined El Pending
Circumstances Investigation
ILI Medical Certifier Name Title
DEBORAH MARSHAT,T„ NO
Address
AMC-UIHLEIN MERCY CENTER, LAKE PLACID, NY
Death Certificate Filed District Number Register Number
City, Town or Village NORTH ELBA 1560
['Burial Date Cemetery or Crematory
03/21/12 PINE VIEW CREMATORY
❑Entombment Address
;❑{Cremation GLENS FALLS, NY
Date Place Removed
Z Removal and/or Held
C4 ❑and/or
� Address
leiHold
d Date Point of
135❑Transportation Shipment
O 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 I)' (,
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
2 Address
ir
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1.7: Permission is hereby granted to dispose of the human rema' s de r ed a ove as indicated.
Date Issued 0 3/21/12 Registrar of Vital Statistics
(signaturey
ii DistrictNumber01072 Place LAKE PLACID-NORTH ELBA, NY 1;'Z1t1�te
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition -Dpri, Place of Disposition one CI;et4 Cr G` 'tJm
(address)
iii
to
Er
(se / (lot number) (grave number)
• Name of Sexton or P rson in Char of Premises t ti'✓t0-117
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z — (please print)
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Signature TitleQ --ry)c_ASS4.
(over)
DOH-1555 (02/2004)