Loading...
Kirkner, Mildred NEW YORK STATE DEPARTMENT OF HEALTH i ilk ir7 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Mildred R Kirkner female Date of Death Age If Veteran of U.S. Armed Forces, Mar 19, 2013 72 War or Dates 1- Place of Death Hospital, Institution or Z Oitg, Town or Village Tupper Lake . Street Address Mercy Living Center iii 0 Manner of Death Natural Cause 0 Accident 0 Homicide Suicide Undetermined Pending LU Circumstances Investigation W Medical Certifier Name Title L3 Avi Hettana MD Address 114 Wawbeek Ave Tupper Lake, NY 12986 Death Certificate Filed District Number Register Number 9 , Town or iaie Tupper Lake 1650 ❑Burial Date Cemetery or Crematory Mar 25, 2013 Pine View Crematory ❑Entombment Address j ©Cremation ___ Queensbury, NY � DU Date lace Removed Removal and/or Held and/or Address to Hold U) O Date Point of IL ❑Transportation ' Shipment Gs 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 1 Remains are Shipped, If Other than Above 2 Address in IL Permission is hereby granted to dispose of the human remain ascribed above as i dilated. / Date Issued Mar 20, 2013Registrar of Vital Statistics Z (' ( ( '' ' , ; ,< < ,4'. nature) District Number 1650 Place Tupper Lake ' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: k. Hi Date of Disposition 10'V)-13 Place of Disposition �.-it/u� Grim 2 (address) Ui 1E (section) (IQt number) (grave number) in Name of Sexton or Person in Charge f Premises �) 3PIt 2 lease print) Signature 4G-- Title CWEMM .. (over) DOH-1555 (02/2004)