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Ficik, Maria NEW YORK STATE DEPARTMENT OF HEALTH/ " ' titi($ Vital Records Section Burial - Transit Permit Name First Middle Last Sex Maria Ficik Female Date of Death Age If Veteran of U.S. Armed Forces, August 2,2013 93 War or Dates 1-, Place of Death Hospital, Institution or Z City, Town or Village North Elba Street Address AMC-Lake Placid pManner of Death n Natural Cause Accident I I Homicide I I Suicide Undetermined f (Pending W Circumstances Investigation w Medical Certifier Name Title O Frank Whitelaw Coroner Address 60 Maple Lane,Bloomingdale,NY 12913 Death Certificate Filed I District Number Register Nupi r City, Town or Village Town of North Elba 1560 'G(J ❑Burial Date Cemetery or Crematory Entombment August 5,2013 Pine View Crematory Address ©Cremation 21 Quaker Rd.,Queensbury,NY 12804 Date Place Removed Z I I Removal and/or Held O and/or Address Hold Cl) O Date Point of yTransportation Shipment • 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 • Address W a Permission is hereby granted to dispose of the human re escr d above as indicated. Date Issued 08-05-2013 Registrar of Vital Statistic (signature) District Number 1560 Place Town of North Elba I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition Place of Disposition iZtOit j C ct0(,�r... (address) CO (section) (lot number) (grave number) pName of Sexton or Person in Charge f Premises . I(F, Q)L.- imut 41z (phase print) 9 W Si nature A Title (over) DOH-1555(02/2004)