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Clark, Kent Frances NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Kent Frances Clark Male Date of Death Age If Veteran of U.S.Armed Forces, 03/13/2020 66 Years War or Dates Place of Death Hospital,Institution or all City,Town or Village Granville Town Street Address Haynes house of Hope p Manner of Death ©Natural Cause Accident Homicide Suicide Undetermined Pending W Circumstances Investigation W Medical Certifier Name Title Charles Yun MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Granville 5756 14 ❑Burial Date Cemetery,Crematory or Facility Name 03/21/2020 Pine View Crematorium Entombment Address Cremation Queensbury Town,New York Donation z Removal Date Place Removed and/or and/or Held F- Hold Address N aDate Point of CO) Transportation Shipment p by Common Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition orto 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 03/17/2020 Registrar of Vital Statistics JennyGinda 9WarteCCe(ECectronicaCCySignec) (signature) District Number 5756 Place Granville, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H Z Date of Disposition z1-ZZ�, Place of Disposition de a WSC (address W N (Sedron) Aot munzfber/ (grave number) Name of Sexton or Person in Char of Premises lease print) Signature �L ° Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b)` ° 4 Receipt Human remains of . - delivered on / d �� �'20 Pjhe View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# ` .f