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Clark, Theresa NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit iin Name First Middle ast Sex Date of Death Age If Veteran of U.S. Armed Forces, /0//9/9s 77 War or Dates /V© ig Place of Death Hospital, Institutimor City, Town or Village Street Address j c4. 1 Manner of Death irk,Natural Cause 0 Accident 0 Homicide EJ Suicide 0 Undetermined ri Pending Circumstances Investigation Medical Certifier Name - ,_ Title A dress .cd0-cc . L....). .G � - Death Certificate Filed District Number Regis fir,Number >> City, Town or Village J (7 Co �--,�' Date Cemet Cre atory L!1 Burial ja//e/ r Address ❑Cremation Date Place Rerp(oved V❑Removal and/or Held �• and/or Address lg Hold Q Date Point of NQ Transportation Shipment a by Common Destination Carrier 0 Disinterment Date Cemetery Address Reinterment Date Cemetery Address giii Permit Issued to Registration Number Name of Funeral Home SULLIVAN.1MI1NARANIPOTTER.INC. O/' '7 7 >_ Address 67 PARK STREET GLENS FALLS NY 12801-4454 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address W f iiii Permission is hereby granted to dispose of the huma re ins duo ibed bove as indicated. Date Issued /®//7/91 Registrar of Vital Statisti s 0.-CIA-`,P L,, nature) '` District Number s-j_s'7 Place I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:'1,;; Cor. Pine St. & Luzern F 6 Date of Disposition 10/18/95 Place of Disposition St. Alphonsus Cemetery, Queensbury, NY 12804 2 (address) LU Section II, Row E 28 1 IC (section) (lot number) (grave number) 0 Name of Sexton or Person in Charge Premises Rev. Robert W. Powhida ' I (please print) LV Signatura W , Title Pastor DOH-1555 (10/89) p. 1 of 2 VS-61