Jackson, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH f J 7 l
Vital Records Section Burial - ransit Permit
Name First Middle Last Sex
Elizabeth M. Jackson Female
Date of Death Age If Veteran of U.S.Armed Forces,
September 25,2013 99 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Lake Placid Street Address 71 Oneida Ave.
WManner
of Death X Natural Cause Accident Homicide [Suicide Undetermined Pending
V Circumstances Investigation
Q Medical Certifier Name Title
Woods McCahill,MD M.D.
Address
Placid Memorial Health Center,AMC-Lake Placid,Lake Placid,NY 12946
Death Certificate Filed District Number Registef mber
City, Town or Village Village of Lake Placid 1523
❑Burial Date Cemetery or Crematory /
Entombtr�ent September 27,2013 Pine View Crematory
Address
0 Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
Hold
to
O _ Date Point of
u) Transportation Shipment
a 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
H Remains are Shipped, If Other than Above
2 Address
W
Permission is hereby granted to dispose of the human rem ' des y ed above as indicated.
Date Issued 09-27-2013 Registrar of Vital Statistics ‘49Y/i'/C Ltri
(signet re)
District Number 1523 Place Village of Lake Placid
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition 115013 Place of Disposition 2,a0 > „�.
W (address)
t/)
(section) (!ot nu ber) (grave number)
pName of Sexton or Person ' Charge of remises siptif
Z (plee print)
W Signature Title CU tti`
(over)
DOH-1555(02/2004)