Stark, John •
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Middle Last Sex
Name First JOHN MATTISON STARK Male
Date of Death Age If Veteran of U.S. Armed Forces,
• October 14, 1999 52 __ War or Dates
>. Place of Death Hospital, Institution or
b City, Townor Village
Glens Falls, NY Street Address Glens Falls Hospital
Undetermined n Pending
,, Manner of Death Natural Cause Accident {�Homicide Suicide '1 Circumstances Investigation
Medical Certifier Name
Title
John Weinhold, MD
Address
Park St Glens Falls, NY 12801 District Number
Death Certificate Filed Register Number
--_ , f
5h01
City, Town or Village Glens Falls, nY
Date Cemetery or Crematory
Ind Burial October 15, 1999
• Ac .css
Y
❑Cremation Ridge Rd Queensbury, Place Removed
Date
F Removal and/or Held
L and/or Address
r. Hold
0 Date Point of
N n Transportation
Shipment
by Common Destination
Carrier Cemetery Address
nDate Disinterment _
Date Cemetery Address
Reintermenl N Registration Number
ameofsuedro Funeral Home Sullivan Minahan & Potter Funeral Home 01824
Name of
Address
_407 Bay Rd �ueensbu _y, NY t 2804—_
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
a6tPi
Permission is hereby granted to dispose of the human remains described abo as' di at d.
Date Issued 10/14/99 Registrar of Vital Statistics
(signature)
M. District Number
5601 Place City of Glens Fal
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ice y r
,,
Place of Disposition
W Date of Disposition 0 S (address)
Nction (lot number) (grave number)
CC
AName of Sexton or Person in Charge of Premises please print) C
g - Title
Signature
(ovc
DOH-1555 (9/98)