Preston, Ralph # 3121
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ,. Burial - Transit Permit
Name First Middle Last Sex
Ralph J. Preston Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 12,2012 60 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village North Elba Street Address 12 Patch Lane
pManner of Death {XJ Natural Cause Accident Homicide Suicide Undetermined 1 Pending
LU Circumstances Investigation
W Medical Certifier Name Title
CI C.David Merkel,M.D.
Address
19 Church Street,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 July 13,2012 Pine View Crematory
Address
Ox Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
U)
0 Date Point of
0.
u) Transportation Shipment
a 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
i— Remains are Shipped, If Other than Above
2 Address
tu
a Permission is hereby granted to dispose of the human rem s desc . d a ove as indicated.
Date Issued 7-13-2012 Registrar of Vital Statistics 6,,LiA(,( 4f-g
(signatu
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:
w Date of Disposition 1.11.0. Place of Disposition .RJ) C vf7rt�_
(address)
N
(section) r (lot numberk—'' I' (grave number)Name of Sexton or Person in Charge of Premi es Ihj�,rir r J1 IT
Z r(please print)
Signature Title Ca€w 1.npo
�_l (over)
DOH-1555 (02/2004)