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Talley, Bethany NEW YORK STATE DEPARTMENT OF HEALTH IL f 7 Vital Records Section t x Burial - Transit Permit Name First Middle Last Sex BETHANY HEL2NE TALLEY FEMALE Date of Death Age If Veteran of U.S. Armed Forces, 0 3/10/2 012 3 2 War or Dates } Place of Death Hospital, Institution or Z City, Town or Village harrietstown Street Address ADRK MEDICAL CENTER Manner of Death©Natural Cause El Accident O Homicide Suicide Undetermined Pending I I. Circumstances Investigation W Medical Certifier Name Title 0 C. FRANCIS VARGA, MD Address PO BOX LAKE PLACID, NY 12946 Death Certificate Filed District Number Register Number << City, Town or Village HARRIETSTOWN OBurial Date Cemetery or Crematory 03/15/2012 PINE VIEW CREMATORY `_> [Entombment Address it 13Cremation GLENS FALLS, NY Date Place Removed O Removal and/or Held and/or Address CO Hold ' Date Point of f'0 Transportation Shipment in by Common Destination Carrier Q 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 lacyf, Name of Funeral Firm Making Disposition or to Whom 14 Remains are Shipped, If Other than Above Address 1r to ' Permission is hereby granted to dispose of the human remains described above 'ndicated. Date Issued 03/12/12 Registrar of Vital Statistics (sig ture) District Number Place Village of Saranac Lake I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: k LU ?Date of Disposition g T%b- „z 2_ Place of Disposition f;� ne J i'.e Ct-era a lc►r-i'u wl (address) ILI {sectio (lot number) (grave number) CI C Name of Sexton or Person in Char of Premises ( i)nA4-it1 1 tu,ie/(C � `(please print) �/ Signature 4`y� 13,,., Title r�m u`t( 7 45 (over) DOH-1555 (02/2004)