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Devlin Jr, Matthew NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Trans it P r it Name First Middle Last Sex Matthew Burley Devlin,Jr. Male Date of Death Age If Veteran of U.S. Armed Forces, August 22,2013 66 War or Dates Place of Death Hospital, Institution or Z City, Town or Village North Elba Street Address 15 Dandelion Way ▪ Manner of Death X Natural Cause Accident Homicide J Suicide [Undetermined Pending Circumstances Investigation w Medical Certifier Name Title 0 David A.Johnson,MD Address 2249 State Rt.86,Saranac Lake,NY 12983 Death Certificate Filed District Number Register Number City, Town or Village Town of North Elba 1560 ❑Burial Date Cemetery or Crematory Entombment August 23,2013 _Pine View Crematory Address ©Cremation 21 Quaker Rd.,Queensbury,NY 12804 Date Place Removed Z Removal and/or Held and/or Address Hold rn 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 H Remains are Shipped, If Other than Above 2 Address 0. Permission is hereby granted to dispose of the human rem�, de/sccrib, abov'enas,indicated. Date Issued 08-23-2013 Registrar of Vital Statistics �Al G l�il�A(` (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: ui• Date of Disposition 4 /51(3 Place of Disposition 124 l (address) W N cc (section) ,J(pt nubed (grave number) pName of Sexton or Person in Charge of Premises l A r+t /41— Z (plea print) w Signature � � Title eizcti/7 (over) DOH-1555(02./2004)