Saloetnik, John INNEW YORK STATE DEPARTMENT OF HEALTH '_` I S"
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John Saletnik Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 31,2013 91 War or Dates
H Place of Death Hospital, Institution or
Z City, Town or Village North Elba Street Address 38 Liberty Hill Lane
Manner of Death '�Natural Cause Accident Homicide Suicide Undetermined - Pending
W Circumstances Investigation
w Medical Certifier Name Title
O Josh Swartzburg MD.
Address
Church St.Lake Placid,NY 12946
Death Certificate Filed District Number Register Number/v.
City, Town or Village Town of North Elba 1560
❑Burial Date Cemetery or Crematory
❑Entombment April 1,2013 Pine View Crematory
Address
El Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z 1-1 Removal and/or Held
and/or Address
H Hold
M
p Date Point of
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
a. Permission is hereby granted to dispose of the human remai described a ve as indicated.
Date Issued 04-01-2013 Registrar of Vital Statistics Q4y(((Ga) `
(signatu )
District Number 1560 Place Town of North Elba
H
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
tit Date of Disposition 4I-+{•t3 Place of Disposition ,;tOtia �-
orivA-
t (address)
tL
CO
re (section) � (lot number) (grave number)
Q Name of Sexton or Person in Charge f Premises `rc$14,- �?hrolf
Z (0ease print)
to Signature 4\sL_ Title (-VC r'1R C(JtZ.
(over)
DOH-1555(02/2004)