Wilbur, Ward •
7/b'
NEW YORK STATE DEPARTMENT OF HEALTH ( 3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ward Guy Wilbur Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 25,2013 65 War or Dates Unknown
f Place of Death Hospital, Institution or
Z City, Town or Village Harrietstown Street Address 19 Morris Way
pManner of Death Natural Cause Accident X Homicide Suicide Undetermined Pending
W Circumstances Investigation
u Medical Certifier Name Title
G Ronald B.Keough Coroner
Address
40 Academy St.,Saranac Lake,NY 12983
Death Certificate Filed District Number Register Number
City,Town or Village Village of Saranac Lake 1663
❑Burial Date Cemetery or Crematory
Entombment November 29,2013 Pine View Crematory
Address
0 Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
F Hold
0
0 Date Point of
NI I Transportation Shipment
a 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
W
O. Permission is hereby granted to dispose of the human remains described abs indicated.
t %`
Date Issued 11-27-2013 Registrar of Vital Statistics 1£ VA. 9 ' I
(sr nature)
District Number 1663 Place Village of Saranac Lake
H
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
u Date of Disposition l��i� Place of Disposition 2.diQ 6--c.
(address)
W
CO
Ce (section) (lot number)cc (grave number)
pName of Sexton or Person in harge of P emises ((Litt'- 30ra-4 -
Z lease print)
LIJ
Signature 4=J---.. Title C121ia
(over)
DOH-1555 (02/2004)