Plausteiner, Jana NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle Last Sex
Jana Plaustener...____.. E.e.ma.l.e_......
Date of Death Age if Veteran of U.S.Armed Forces,
11 14 88
W ...No..::::...:::....::....:......:........ ...... ..........................E ........................::::. _...._..._................_._...._... ..
Place of Death Hospital, Institution or
City,Town or Village Street Address
9Lake:..Pl...... ...:..._.... ................................._._.U.i.h. .ea..n...Mex.C. ..._C.ent.e.r.. .............._._.. .....................................................
..............................................................y.........................................................
Cause of Death
C a.s c into ma_..
:Is41: Medical Certifier Name Title
Address
::......:::,::::..:::::,:. _::::..:::..:::....::...:.....:.....................
Death Certificate Filed District Number : Register Number
City,Town or Village Lake Ilacid 1560
Date Cemetery or Crematory
❑Burial
::............... .::::::...!..I/17�88P necr,ema:t:4:xy:::::::.::,:::::._:.
Cremation : Address
GlensFalls. N......Y. :.. .:.. _ ......_..... _._.........__..._ ....... .. .._. ._..._.. ......... _ ...... :...........,.....:.:................ ..... ..
Z; Date Place Removed
0; Removal and/or Held
and/or Hold`:.................................::..:...............................::::::._::::...... .::::::::.::::::::::::::::::::::::::.....:::::::::::::::.::::::::::.,::::::,::::::.::::,::::::,:::::::::::::::::.,::::::::::::::::::::::::::
Address
1] ; Date Point of
Q Transportation by Shipment
Common Carrier ...................................................................................................................................................
.............:... ._ ..... _....... ._...
Destination
:::....:......:......... :::.... .......................:......:.. ..................................
Disinterment Date Cemetery Address
Reinterment Date " Cemetery Address
Permit Issued to : Registration Number
Name of Funeral Firm M B Clark, Inc . `004�22
;::::Address:.:::.........................................................................................................................................................................................................................................
.................
2 Sara
.......__..__................_.........._....._.......7.._...._.........nac Ave. Lake..Placid_. ... ...__.__.. ...._.........._. ..... .... ._..............._.....
..
........................................................................................:.....................::.....,...:...:.::::.....:.......::::..:.:.:.....................................................................................................:....::::.
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the dead human remains described above as Indicated.
Date Issued 11Z16/88 Registrar of Vital Statistics 1 .�,, _L_. r� l �1 , �J kt,
(signature)
District Number 1560 Place Lake Placid
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition I/V/ lV—/,16- l� �'j.��,/j�/7 /�'. !11
� p /" Place of Disposition /
(address)
W
(section) (lot number) (grave number)
pName of Secton or arson in C rge of Premis s /52&4d Y. X 72
Z (please print)
Lull
Signature Title /C1
DOH- 1555(9/86)p 1 of 2(formerly VS-61)