Clark, Meredith 4, t o�
NEW YORK STATE DEPARTMEZIT OF HEALT
Vital Records Section _ ,Kr 1 Burial - Transit Permit
Name First �•ole Last Sex
Meredith R Clark , Male
Date of Death A If Veteran of U.S. Armed Forces,
07/26/2018 82-relors War or Dates
Place of Death Hospital, Institution or
r: City, Town or Village Johnsburg Town r Street Address Adirondack Tri-County Nursing And Rehabilitation Center,Inc.
ri Manner of Death X❑Natural Cause OvAccident ❑Homicide ❑Suicide ri❑Undetermined ❑Pending
ILI Circumstances Investigation
Medical Certifier Name Title
James Hindson MD
Address
112 Ski Bowl Rd,Johnsburg Town,New York 12853
. Death Certificate Filed District Number Register Number
City, Town or Village North Creek 5655 19
❑Burial Date Cemetery or Crematory
07/27/2018 Pine View Crematory
0 Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
it❑Removal and/or Held
g and/or Address
Hold
Date Point of
❑Transportation Shipment
t, by Common Destination
Carrier _
❑Disinterment Date Cemetery Address
❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
'4 '- 3809 Main St,Warrensburg,New York 12885
• s Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
04.14
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/26/2018 Registrar of Vital Statistics Kathleen C Lorah('Electronically Signed)
;, (signature)
District Number Place
5655 North Creek, New York
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LUI Date of Disposition ')-3o-I Place of Disposition p;pc,rGv C.fc wtq.lat'y
lfl (address)
IC (section) (lot number) (grave number)
QName of Sexton or Person in Charge of Premises Sc! My Svt r. S
Z (please print)
Signature Title _ C,1 4c for
(over)
DOH-1555 (02/2004)