Clark, Nada 1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
::r: Name First Middle Last Sex
Nada M. Clark Female
:rr Date of Death Age If Veteran of U.S. Armed Forces,
April 15, 2014 76 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
0.1 Manner of Death I XI Natural Cause Accident I !Homicide Suicide Undetermined 'Pending
Circumstances Investigation
Medical Certifier Name Title
gi Robert W. Sponzo
Address
Cancer Center, 102 Park St,Glens Falls,NY 12801
* Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 j CI 0
❑X Burial Date Cemetery or Crematory
April 19, 2014 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road, Queensbury, , NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
Cl)
O Date Point of
U) Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
IAddress
• Permission is hereby granted to dispose of the human remains described above as indicated.
:▪::: Date Issued LI t I "7 f l �f Registrar of Vital Statistics L-) , � .A1)\.^-ce\-A,A
-
:* (signature)
K:
• District Number 5601 Place Glens Falls
:r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 4/1 9/1 4 Place of Disposition Pine View Cemetery
2 (address)
W N Huron 27 E
CC (section) (lot number) (grave number)
pName of Sext n or Person in Charge of Premises Connie L. Goedert
Z / (please print)
W
Signature /202.c_e .-X' -e Title Superintendent
(over)
DOH-1555(02/2004)