Clark, Caryl NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last 1 Sex
COA4212r1 r1� F
Date of Death I Age If Veteran of U.S. Armed Forces,
2 2 2 11 War or Dates
Place of Deat Hospital, Institution or//
City, Town or ills e { ` Street Address CPS cGi�'l l�'S e, v
Manner of Death®Natural Cause []Accident [:]Homicide []Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Address
319 6 C C2i VeeoS b LQJ r28c�f
Death Certificat 'led District Number Register Number
City, Town o ills
❑Burial a e Cem tery or Crematory
❑Entombment 2 1 3c 2�9 �,.� re C
Address
(RCremation 21 1 2 304
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
i
Reinterment Date Cemetery Address
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Permit Issued to I Registration Number
Name of Funeral Home Baker Funeral Home j 01130
Address
11 Lafayette St., Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IM
Permission is hereby granted to dispose of the human retnains described above as indicated.
Date Issued f Registrar of Vital Statistics
"`7 t-*-- (signature)
District Number L._6z�o_._ _ Place
I certify that the remains of the decedent identified above re disposed of in accordance with this permit on:
Date of Disposition /2-3/-/9 Place of Disposition ��'�e�,e,c1 B ae r"'- 9
(address)
W
{section) (lot number) (grave number)
Name of Sexton or P rson in Charge of Premises 11
("please pent)
Signature A Title Gi>;►�'`c�' ��
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) 013192
Receipt
Human remains of delivered on , 20
-4 ejew Cemetery Representing the funeral home named on burial permit
Official 'Funeral Directors Reg.or License#
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