Barney, Maude NEW YORK STATE DEPARTMENT OF HEALTH * 1 vita cards Section . Buda! - Transit Permit
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Name First Middle Last Sex
Maude H. Barney Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 8,2012 81 War or Dates
F- Place of Death Hospital, Institution or
Z City,Town or Village Harrietstown Street Address Adirondack Medical Center
p Manner of Death a Natural Cause fl Accident [Homicide piSuicide n Undetermined 'Pending
Ili Circumstances Investigation
W Medical Certifier Name Title
G
Address
Death Certificate Filed ' District Number Register Number
City, Town or Village Town of Harrietstown 1663 1
❑Burial Date Cemetery or Crematory
Entombment 08-13-2012 Pine View Crematory
Address
®Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date I Place Removed
Z FiRemoval I and/or Held
O and/or I Address
�• Hold
4 Date Point of
N C Transportation Shnent
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
5eInterment 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 T
Z
w
t1.4 Permission is hereby granted to dispose of the human remai ascribed above a ,in cated.
Date Issued 08-09-2012 Registrar of Vital Statistics
(signet e)
District Number 1663 �.Plata Village of Saranac Lake
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition i-64.. _ Place of Disposition ,�,tUkv Crd..trto.,
W 4 (address)
CO
CZ
0 4(section) '�(1 t number) C (grave number)
ca Name of Sexton or Person in Charge o Premises t t r` ta►fi}
Z ( lease print)
W Signature A �, g Title CnEfr �i'1-
(over)
DOH-1555(02/2004)