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Higgins, Elizabeth i . v "k 3 ta NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit # Name First Middle Last Sex Elizabeth M. Higgins Female Date of Death Age If Veteran of U.S.Armed Forces, June 9,2013 82 War or Dates L. Place of Death Hospital, Institution or Z City, Town or Village North Elba Street Address 24 Cherry Lane p Manner of Death i Xi Natural Cause + 'Accident Homicide Suicide 1 I Undetermined 1 Pending Circumstances Investigation w Medical Certifier Name Title o Viola M.D. Address ,Lake Placid,NY 12946 Death Certificate Filed District Numbet560 Register Number City, Town or Village Town of North Elba ❑Burial Date Cemetery or Crematory Entombment June 11,2013 Pine View Crematory Address ©Cremation 21 Quaker Rd.,Queensbury,NY 12804 Date Place Removed ZZ 1 1 Removal and/or Held and/or Address N Hold W O Date Point of • 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 te 0. Permission is hereby granted to dispose of the human rem: escr d a ve as indicated. Date Issued 06-10-2013 Registrar of Vital Statistics rem: (signature)/ District Number 1560 Place Town of North Elb• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: w Date of Disposition (,- j2't3 Place of Disposition a tU (address) CO (section) lot num r) (grave number) Z Name of Sexton or Person in Charge of Premises �jt'. ' ,y.I Z (pleas pent) Signature 4 ..."-.-s-_ Title Ca'*Iito(L (over) DOH-1555(02/2004)