Clark, Linda Mae A
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Linda Mae Clark Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/30/2020 77 Years War or Dates
i. Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
'p Mannerof Death LI �Natural Cause ❑Accident Homicide Suicide Undetermined Pending
C.) Circumstances Investigation
QMedical Certifier Name Title
Shahid Ahmed MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 51
❑Burial Date Cemetery,Crematory or Facility Name
01/31/2020 Pine View Crematory
Entombment Address
Cremation Queensbury,New York
Donation
0 ❑Removal Date Place Removed
and/or and/or Held
H to Hold Address
O
IL Date Point of
N ❑Transportation
jS by Common Shipment
Carrier Destination
❑Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
.� Address
Q
W
(L Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/31/2020 Registrar of Vital Statistics RoAeg ghdrewCurtzr(-Yectron-ad Srgne4
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition a o Place of Disposition '1:;),' [� r
(address/
W
N
IM (section) (lot number) (grave number)
SName of Sexton or Person in Cha f Premises r
Z (please print)
W Signature f C Title
DOH-1555(o7/18)p 1 of 2
Clark
NAME Linda Clark Age:
77
Lot Owner:
Linda April
Lot# Grave#
Mohawk 76 2
Case: URN
Died: /30/2020 Interred:
11 /2020
Funeral Home:
Regan, Denny, Stafford
Cemetery:
Pine View
Public Health Law Sec. 4145(2b) .'
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#