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Selleck, Nathaniel NEW YORK STATE DEPARTMENT OF HEALTH g7LZ Vital Records Section Burial - Transit Permit Name First Middle Last Sex Nathaniel P. Selleck,M.D. Male Date of Death Age If Veteran of U.S. Armed Forces, December 11,2013 85 War or Dates World War II F-, Place of Death Hospital, Institution or Z City' t wt or Village Keene Street Address 102 Molly Nye Lane pManner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation 0ul Medical Certifier Name Title Elizabeth Buck,KB KB Address Lake Colby Drive,Saranac Lake,NY 12983 Death Certificate Filed District Number Register Number City, Town or Village Town of Keene 1555 ❑Burial Date Cemetery or Crematory ❑Entombment December 13,2013 Pine View Crematory Address ©Cremation 21 Quaker Rd., Queensbury,NY 12804 Date Place Removed Z Removal and/or Held and/or Address Hold N O Date Point of N I 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 -. Remains are Shipped, If Other than Above 2 Address t'C W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12-11-2013 Registrar of Vital Statistics t t+-N (signature) District Number 1555 Place Town of Keene I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: w Date of Disposition 014,113 Place of Disposition Rivat,,, (address) N (section) /5(lot number) r (grave number) pName of Sexton or Person in Charge of Premises Z (plebse print) Signature Title Ctf tank (over) DOH-1555(02/2004)