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Clark, Janice Brandon
N EW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Janice Brandon Clark Female Date of Death Age If Veteran of U.S.Armed Forces, 02/26/2020 72 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Saratoga Springs Street Address Saratoga Hospital W Undetermined Pending W Manner of Death ©Natural Cause �Accident �Homicide �Suicide Circumstances Investigation W Medical Certifier Name Title Mark Weidner MD Address 211 Church St,Saratoga Springs,New York 12866 Death Certificate Filed District Number Register Number City,Town or Village Saratoga Springs 4501 130 Burial Date Cemetery,Crematory or Facility Name 02/28/2020 Pine View Crematory Entombment Address Cremation Queensbury,New York ❑Donation O ❑Removal Z Date Place Removed and/or and/or Held ~ Hold Address N O G. Date Point of U) ❑Transportation Shipment p by Common 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 W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/28/2020 Registrar of Vital Statistics ,yokn Tauffranck(ECectronicalTy Signed) (signature/ District Number 4501 Place Saratoga Springs, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 21791710 Place of Disposition (address) W N (section) /ot number) (grave number) Ix 8 Name of Sexton or Person in Charge of Premise Z (Pleasu print) W Signature Title DO H-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 1) L 3 3 r 5 Receipt Human remains of delivered on , 20— Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#