Page, Howard NEW YORK STATE DEPARTMENT OF HEALTH 'T- ��[S(
Vital Records Section Burial - Transit Perini
Name First Middle Last Sex
MOWRXX tiN4i'§ HOWARD PAGE
MALE _
Date of Death Age If Veteran of U.S. Armed Forces,
MAY 11 , 2012 97 War or Dates
j. Place of Death Hospital, Institution or
Z SARANAC LAKE 78 WILL ROGERS DRIVE
--wG+ -e+Village Street Address
in Manner of Death n Natural Cause ( I Accident I I Homicide n Suicide Undetermined 1 I Pending
ILI Circumstances Investigation
Q.
Medical Certifier Name Title
C.) WOODS McCAHILL, MD
Address
JOHN BROWN ROAD, LAKE PLACID, NY
Death Certificate Filed District Number Register Number ;ir14 o
Village SARANAC LAKE 1524
'�
El Burial Date MAY 15, 2012 Cemetery or Crematory
PINE VIEW CREMATORY PINE VIEW CREMATORY
M.i ❑Entombment Address
aCremation GLENS FALLS, NY
Date Place Removed
Z Removal and/or Held
'and/or
Address
tall:
Hold
C` . Date Point of
Ili�C
Transportation Shipment
by Common Destination
Carrier
QDisinterment Date Cemetery Address
iiM
4:2Q Reinterment Date Cemetery Address
pi Permit Issued to Registration Number
Name of Funeral Home M• B. CLARK, INC. 01075
Address
:< < 310 SARANAC AVE• , LAKE PLACID, NY
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
: Address
CC
111
B' Permission is hereby granted to dispose of the human rem ins described above s dicated.
Date Issued 0 5/14/12 Registrar of Vital Statistics
(signet
ki District Number isil Place Village of Saranac Lake
'" I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z +'
ILI Date of Disposition 5 J f6I(Z Place of Disposition •RHUKJ C, (arks
2 (address)
ID
U)
Cr (section) (lot number)_� (grave number)
tj Name of Sexton or Per on in Charge f Premises At+ f Y' J`s/f
M (please print)
114
. Signature Title Ctli h .
(over)
DOH-1555 (02/2004)