Clark, Muriel i`s W YORK STATE DEPARTMENT OF HEALTH
x\ Vital Records Section Burial - Transit Permit
L.
<r Name First
ENMiddle Last I Sex 1
Hurt-C. C\Qr\� i F
'` Date of Death Age I If Veteran of U.S. Armed Forces, `/
bS 12—{ 12p1S War or Dates IV1 r-
"'
' Pl.ce of Death ' Hospital, Institution or
. Town or Village (�( Q c VG\\S I Street Address 6 T LQ,ns rows 1-4-4E4 (
,,; Manner of Death}�Natural Cause Accident n Homicide (�Suicide
\` n Undetermined n Pending
Medical Certifier Name Circumstances Investigation
'.. )—Ct r'h Ct no, \�Q n 1 Title M
Address
Death Certificate Filed �--��\�S P�1� � ��
". City, Town or Village District Number C/O�L�fj Register Numberj�
Date 9l �l i I
bg �\ i Ceme ���rematory
NI Burial I \ 201 Q. CCM.�
Address
Cremation!
Q V.Qe � N
Date ��7 : Place Removed
2 I I Removal ,
and/or ' and/or Held
Address --— Hold
"+ Date
N Transportation hinm of
Shipment
a by Common Destination,
Carrier
<f��Disinterment Date Cemetery Address
�:-:: —1 Date; Y ; Cemetery Address
I Reinterment
1,•;,,:
� " Permit Issued to _
� > Name of Funeral Home �(SCC er h e(CL/ I/omZ Registration Number
Address ; i Of I
1/ /_C_ 1 • ,s
1"` Name of Funeral Firm Making Disposition or to Whom J
Remains are Shipped, If Other than Above
:a- Address
<' Permission is hereby granted to dispose of the human remains described above as indicated.
'> Date Issued S 12Z( L5 Registrar of Vital Statistics W
1 (signature)
<: District Number �60 ( Place 6 v\S VG\\ 5 )
:::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i4
E Date of Disposition 8/31 /1 5 Place of Disposition Seeley' s Cemetery, Queensbury, NY
IM
(address)
1C/ Clark Family Plot
(section) (lot number) (grave number)
C Name of Sexton or Person in Charge of Premises Connie L. Goedert
2 „<,`..:7 (please print)
14 SignaturdL-o''jLe ,
`� Title Cemetery Superintendent
:over)
DOH-1555 (9/98)