Davis, Marceline NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial --Transit Permit
Name First Middle Last Sex
MARCELINE DAVIS FEMALE
Date of Death Age If Veteran of U.S. Armed Forces,
J AN 24, 19 9 9 86 War or Dates
Place of Death Hospital, Institution or MOSES LUDINGTON NURSING
City, Town or Village TICONDEROGA Street Address
Manner of Death ®Natural Cause Accident ❑Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
T. S. WEBB MD.
Address
OLD CHILSON RD. TICONDEROGA Y 12883
Death Certificate Filed town District Number Register Number
City, Town or Village TIC ND ROGA 1564 9 _
Date Cemetery or Crematory
❑Burial July 7 1999 Pine ViewCrematory
Address
®CNY
remation Glens Fa
Date Place Removed
8 ❑Removal and/or Held
�.• and/or Address
Hold
Q Date Point of
Transportation Shipment
by Common Destination
Carrier
Q Disinterment Date Cemetery Address
07 06 1999
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral HoMe Clark, Inc. 01231
Address
27 Saranac Ave. , Lake Placid, NY 12946
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 7/6/99 Registrar of Vital Statistics �. � A_Alljjl III
(signature)
NX
District Number 1560 Place T akQ pia,.; _ (mart-. Elba) XY
I certify that the remains of
the
decedent identified above were disposed of in accordance with this permit on:
` / L / Disposition � /✓ �� ' �A �-' fir,/
F Date of Disposition Place of
(address)
Uj
N
> (section) (lot number) (grave number)
GName of Sexto or Person in Charge of Premises 147_Z9 D Z/j l J
(please print)
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61