Wylie, William NEW YORK STATE DEPARTMENT OF HEALTH # Z Z
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
William Donald Wylie Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 13,2013 68 War or Dates Vietnam
f., Place of Death Hospital, Institution or
Z City, Town or Village Lake Placid Street Address 177 Mill Pond Drive
pManner of Death I XI Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
G Medical Certifier Name Title
Brian Guadagno
Address
2244 Rt.86,Suite 33,Saranac Lake,NY 12983
Death Certificate Filed District Number Register Number
City, Town or Village Village of Lake Placid 1523
❑Burial Date Cemetery or Crematory
❑Entombment May 15,2013 Pine View Crematory
Address
0 Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
9 and/or Address
' Hold
N
0 Date Point of
Pij H Transportation Shipment
p 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 12946
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
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a
Permission is hereby granted to dispose of the human a ins d Zribe. above as indicated.
Date Issued 05-14-2013 Registrar of Vital Statistics V a i%/' ..,
(sign re)
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:
Z
tu Date of Disposition $-IL-C3 Place of Disposition F L. Cr4 _-
(address)
cn
pix (section) �/ )i- (lot numt (grave number)
Name of Sexton or Person in Charge of Premises 1 thlj
Z (please print)
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Signature Title CVjftW
(over)
DOH-1555(02/2004)