Peck, Theodore NEW YORK STATE DEPARTMENT OF HEALTH +Vital Records Section 4 Burial - Transit Perrt -
Name First Middle Last Sex
Theodore O. Peck , Male
Date of Death Age If Veteran of U.S.Armed Forces,
May 4,2012 84 War or Dates
H Place of Death Hospital, Institution or
Z City, Town or Village Street Address AMC-Lake Placid
Manner of Death I X+Natural Cause Accident n Homicide Suicide Undetermined Pending
w Circumstances Investigation
W Medical Certifier Name Title
O Adam Abodeely,MD MD
Address
AMC-Saranac Lake,Saranac Lake,NY 12983
Death Certificate Filed District Number Register Number
City, Town or Village Town of North Elba 1560
❑Burial Date I Cemetery or Crematory
❑Entombment May 7,2012 , Pine View Crematory
Address
XD Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
z ,Removal and/or Held
and/or Address
H Hold
O Date 1 Point of
g Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n 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
rt
O. Permission is hereby granted to dispose of the human rem ns d scr bed above as indicated.
Date Issued 5-7-2012 Registrar of Vital Statistics emit a ( C
ignature)
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:
tit Date of Disposition S-b--ao 12_ Place of Disposition t` ,v j.e (f' v►.�ct ,r;�,,,n
W (address)
N
0 (section) (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises 1,rv1,16 Qru ne/��
(please print)
W Signature �Jl�^v,,`" l J��, �,� Title Cr-cwj4:L,- 4SS4.
(over)
DOH-1555 (02/2004)