Saletnik, Pallas NEW YORK STATE DEPARTMENT OF HEALTH ' - Iiiimit
@�Vital Records Section Burial - TransitII
Name First Middle Last Sex
Pallas Saletnik Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 31,2013 85 War or Dates
f.. Place of Death Hospital, Institution or
Z City, Town or Village North Elba Street Address 38 Liberty Hill Lane
O Manner of Death X Natural Cause Accident 1 1 Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
G Woods McCahill,MD
Address
Placid Memorial Health Center,AMC-Lake Placid,Lake Placid,NY 12946
Death Certificate Filed District Number Register Number/5
City, Town or Village Town of North Elba 1560
❑Burial Date Cemetery or Crematory
❑Entombment April 1,2013 Pine View Crematory
Address
Ll Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
! Hold
Co
O Date Point of
N I '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
C
W
o. Permission is hereby granted to dispose of the human rema' s de ribe above as indicated.
Date Issued 04-01-2013 Registrar of Vital Statistics ifim t€
(sig ture)
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:
Z 1 /1
W Date of Disposition ti-1-13 Place of Disposition . ,..rVw> Cif( -
2 (address)
W
Cl)
CZ (section) / (lot numb (grave number)
pName of Sexton or Perso in Charge of Premises L �� 4, ,4-
Z J (please print)
W Title C¢i=N►I�i O L
Signature _�
(over)
DOH-1555 (02/2004)