Strack, Sr. Larry NEW YORK STATE DEPARTMENT OF HEALTH It I VZ
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
LARRY EDWARD STRACK, SR MALE
Date of Death Age If Veteran of U.S. Armed Forces,
MARCH Z.' L 201:2 63 War or Dates
I.- Place of Death Hospital, Institution or
Z City, Town or Village HARRIETSTOWN Street Address ADRK MEDICAL CENTER
a Manner of Death❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
LtiCircumstances Investigation
Ili Medical Certifier Name Title
DAVID A. JOHNSON, MD
Address
ADRK MEDICAL CENTER, SARANAC LAKE, NY /2 s1>
Death Certificate Filed District Number Register Number
City, Town or Village HARRIETSTOWN 1663
;. ❑Burial Date Cemetery or Crematory
APRIL 2 , 2012 PINE VIEW CREMATORY
['Entombment Address
❑x Cremation GLENS FALLS, NY
Date Place Removed
❑Removal and/or Held
and/or Address
=" Hold
Date Point of
' Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Recur0 r75 on Number
Name of Funeral Home M. B. CLARK, INC. U1
Address
2310 SARANAC AVE. LAKE PLACID, NY 129141
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
Ir
t:
Permission is hereby granted to dispose of the human rem i described above ' dicated.
Date Issued 3/2 3/12 Registrar of Vital Statistics do�_Q��-L
(signatur
District Number 1663 Place Village of Saranac Lake
k>.;>: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
.:
Ili Date of Disposition A , 3l tout Place of Disposition -,,,U,4 t� {oi
(address)
Ili
fill
CC (section) , (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises ir.y{zQ f Si,�4t
Z ditto.— PP please print)
SignatureTitle CMMIfTOfL (over)
DOH-1555 (02/2004)