Clark, Jack NEW YORK STATE DEPARTMENT OF HEALTH a A
Vital Records Section Burial - Transit Permit
2 3t Name First Middle Last Sex
pc
Jack Joseph Clark Male
ggt Date of Death Age If Veteran of U.S. Armed Forces,
12/03/2018 58 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Pottersville Street Address Deceased's Residence
Manner of Death Q Natural Cause El Accident 0 Homicide 0 Suicide 1.2 Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
At
Shannon Evellis,
OW Address
itt 6223 State Rte 9 Chestertown NY 12817
.. ! Death Certificate Filed District Number
City, Town or Village C.,�,e5-���( `- 5Q)5c Register Number
Ito
rf.�'El Burial
DateCrematory
` 12/05/2018 /1 /ems CI-e 4 /0 0 t/ -
:�„,„
❑Entombment �'
Address �� -„, / �, /_, . r
FA®Cremation l� /�/
Date Place Removed
0 Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
'= by Common Destination
Carrier
to, Li Disinterment
Date Cemetery Address
If
#v Reinterment Date Cemetery Address
0 j Permit Issued to
,fi Registration Number
Att Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
Address
'4" 9 Pine St/P.O. Box 455 Chestertown NY 12817
y t Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
i Permission is hereby granted to dispose of the human remains d s ' d above as'ndicated.
Date Issued (a'0`(--, Ul 2 Registrar of Vital Statistics
' (si ture
District Number 5(0. Sa Place `..,, cpc C(Aes��t,—
ii
.k I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
v Date of Disposition I Z/S.Ill' Place of Disposition ?mi.. 41,400t'6....
: (address)
(section) A(lot number) (grave number)
ki 4 Name of Sexton or Person in Charge of P emises t 11t•� ¢�►►+it
a (please print)
$ Signature A Title tiW'4l1YL
(over)
DOH-1555(02/2004)