Horvath, John A 17 7
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Male
John A . Horvath
......... ....
............................................... ........................................... .................................... ............... ...................................................................
Date of Death Age If Veteran of U.S.Armed Forces,
War or Dates....... .94
63 ................................... ... ..
.. .......... ..... ... . .... ..........................................................-
Place of Death Hospital, Institution or
.W. City,Town or Village Lake Placid Street Address Deerwood Trail
........... ....... ..........................-
Manner ................................................................................... ....................................................... .................................................................. ..........
Manner of Death Homicide Natural Cause lXXE] Accident Undetermined
Suicide _] Pending
Circumstances Investigation
................... . ..... ... ....... .............
...... . ................................................. . .................................................................. .. . ........................................ ......
Lti
Medical Certifier Name Title
Waikman, M . D.
Anthony
...........................................................I.................................................................................................................................................................................... .................
Address
Church St . , Saranac Lake, N. Y. 12983
... ....... ........ .........
Death ............................................ ...................................................................................................-............-............................................ ................
Death Certificate Filed District Number Register Number
City,Town or Village Lake Placid 1560
Date Cemetery or Crematory
❑Burial
March 7, 1992 Pine View Crematory
........................-...-............
Cremation Address:
Quaker Road, Glens Falls, N. Y .
......................................................................... ...................... .................................................................... ................ .......
z Date Place Removed
2 El Removal and/or Held
.... ....... ........
..................................................................................... ........I--......................................................... ...................................................
and/or Hold Address
0.......... ........................ ....................I............................................................................. ........................................
Date Point of
Ln F]Transportation by:
Shipment
aCommon Carrier .......................... ........................................ ...... ......... .........-.......... ....................................................................
Destination
................................................. *........................................ .....Cemetery. Address.......
:: .........
❑ Disinterment Date
.................................-.......... .......................... ....................... .........-........ .........................❑ ..11............ .......... ............... ...............................................
:j Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Firm M . B . Clark, Inc . oo3,.67...................
................................. .............................. ............. .................. ................................. ......... .......................... ...
Address
A 27 Saranac ve .
........................ 2.....Saranac .......................... ........Y..................... ................ ...........-...... ..............................
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, H Other than Above
....... ........................ .......... ...............................................................-
��i Address
.... ........ ................ ..................-...........
................................................................................................................................... ............... ..........................
Permission is hereby granted to dispose of the human remains desc ffied above as indicated.
Date Issued 3/6/92 Registrar of Vital Statistics. 10)
......
(signature)
District Number 1560 Place Lake Placid [North Elba] , N. Y .
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LLJDate of Disposition 3-7-?cZ Place of Disposition U; eW C-c&,Q7a:T-or ; (1M
2 (address)
LLJ
(n (section) (lot number) (grave number)
cc
0
a Name of Sexton or Person in Charge of Premises e,
z (please print)
Uj nature -T
Sig Title CjL,?7R, Or
....................................I......I........... ........................... ..................................I.............I--.........................I................................... ..............
DOH-1 555 (10/89) p. 1 of 2 VS-61