Savarie Jr, John NEW YORK STATE DEPARTMENT OF HEALTH it
Vital Records Section r' V Burial - Transit Permit
Name First Middle Last Sex
John II. Savarie,Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 19,2013 65 War or Dates 1967-1976
.. Place of Death Hospital, Institution or
Z City, Town or Village North Elba Street Address 20 Conifer Circle
Manner of Death X Natural Cause Accident Homicide Suicide 'Undetermined Pending
W Circumstances Investigation
y Medical Certifier Name Title
Barry Kilbourne Dr.
Address
309 County Rt.47,Saranac Lake,NY 12983
Death Certificate Filed District Number Register Number
City, Town or Village Town of North Elba 1560
❑Burial Date Cemetery or Crematory
Li Entombment November 21,2013 Pine View Crematory
Address
El Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
to
00 Date Point of
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
I 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
t— Remains are Shipped, If Other than Above
2 Address
W
1L Permission is hereby granted to dispose of the human re desc ed above as indicated.
Date Issued 11-120-2013 Registrar of Vital Statistics // r/
(signature)
District Number 1560 Place Town of North Elba
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LU Date of Disposition ij-LI-13 Place of Disposition Zit." L Ck I-.
(address)
V)
(section) f.(lot number) (grave number)
Z Name of Sexton or Person in Charge of Pre ises //,r,� �*nnif
W (pl ase print)
Signature `� Title 'iyMlA-TX
(over)
DOH-1555(02/2004)