O'Connor, Francis NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transitciltermit
Name First Middle Last Sex
Francis Edward O'Connor Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 5,2013 95 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Keene Street Address 33 Gilmore Hill Rd.
pManner of Death n Natural Cause n Accident Homicide n Suicide Undetermined Pending
Circumstances Investigation
w• Medical Certifier Name Title
Tracey Viola DO
Address
29 Church St.,Lake Placid,NY 12946
Death Certificate Filed District Number Register Number
City,Town or Village Town of Keene 1555
❑Burial Date Cemetery or Crematory
Entombment October 7,2013 Pine View Crematory
Address
I:Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z J (Removal and/or Held
and/or Address
! Hold
Cl)
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n 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
• Address
CL
0. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10-07-2013 Registrar of Vital Statistics tit f rx / .(/)
(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 io/q li3 Place of Disposition �(,ncVuu O/retdr*
(address)
CO
(section) L h (lot number) C (grave number)
O
▪ Name of Sexton or Person 'n Charge of Premises ( .) lna�`f
( lease print)
W at� Title cae minor
Signature
(over)
DOH-1555(02/2004)