Duffy, Mary Lou N.
NEW YORK STATE DEPARTMENT OF HEALTFI #��°-.�
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary Lou Duffy Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 08,2013 72 War or Dates
1 Place of Death Hospital, Institution or
Z City, Town or Village Saratoga Springs Street Address Saratoga Hospital
111
• Manner of Death I XI Natural Cause Accident r Homicide Suicide Undetermined I Pending 1
VI Circumstances Investigation
;' Medical Certifier Name Title
• Mark Weidner MD
Address
211 Church Street,Saratoga Springs,NY 12866
Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs 4501 0
❑Burial Date Cemetery or Crematory
—-Entombment 12/12/2013 Pine View Crematory
Address
0 Cremation Queensbury, New York
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
Cl)
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 PIacid,NY 12946
Name of Funeral Firm Making Disposition or to Whom
i- Remains are Shipped, If Other than Above
2i Address
EL
WO.
Permission is hereby granted to dispose of the human re ins s ibed- as indic ed.
Date Issued 12_1 cqktx.313Registrar of Vital Statistics
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z W U l
Date of Disposition j�-�1-i3 Place of Disposition • � a�.! pf,rv---
2 (address)
W
N
0 p (section) (lot numb (grave number)
Name of Sexton or Perso 'n Charge of Premises /itc- P��
Z (please print)
ilt
Signature /121—
Title C1Zi IflRV C
(over)
DOH-1555 (02/2004)