Clark, Kevin NEW YORK STATE DEPARTMENT OF HEALTH + f`Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kevin J. Clark Male
Date of Death Age If Veteran of U.S. Armed Forces,
w=; January 14,2018 47 War or Dates
ig
Place of Death Hospital, Institution or
City, Town or Village Warrensburg Street Address 29 Burdick Ave.
Manner of Death X Natural Cause I Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
e Medical Certifier Name Title
Z. William Orluk
Address
Chester Health Center,Chestertown,NY 12817
Death Certificate Filed District Number Register Number
City, Town or Village Warrensburg 5660 r9,
❑Burial Date Cemetery or Crematory
❑ January 17,2018 Pine View Crematory
Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
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0 Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
r° Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
X' Address
t
Permission is hereby granted to dispose of the human r ains-7 described
�above as indicated.
Date Issued 1 l e 1 IS Registrar of Vital Statistics 'f9'1• C���,,eeGU
(signature)
District Number 5660 Place Warrensburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z p
Date of Disposition i/i lig Place of Disposition f,:tV.✓ 4.,.t7c,..
W (address)
cn
cc (section) (lot number) (grave number)
Op Name of Sexton or Person in Charge of Pre,mises 4.1(., ..A4P
ase print
W Signature /£' Title (ntnt,f y?re
(over)
DOH-1555 (02/2004)