Clark, Brian NEW YORK STATE DEPARTMENT OF HEALTH r 4 # 15 1
Vital Records Section Burial - Transit Permit
,
'I; Name First Middle Last Sex
W' Brian Arthur Clark Male
Date of Death Age If Veteran of U.S. Armed Forces,
W" 02/27/2018 81 War or Dates
{
Place of Death Hospital, Institution or
City, Town or Village Street Address
Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide El Undetermined ri 1---I Pending
CircumstancesInvestigation
h Medical Certifier Name /74/__ Title
Agee! Gillani,
Address
102 Park Street Glens Falls, NY 12801
k Deat ificate Filed District Number �5� RegisterJumber
City, own Village SQ1n.�5 1CC)K3
ri❑Burial Date Cca .r otr Cjematory
02/28/2018 //fe t77-ems) (72(. 74,/C,r1‘/ i
Kt 0 Entombment Address j / 7
Y .I®Cremation ( 11.-C�ivt�'4 yr _.t/
Date Place Removed /�
;`„..,„
,❑ Removal and/or Held
and/or Address
Hold
Ps Date Point of
' ' ❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
, Date Cemetery Address
" ❑ Reinterment
r Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is he by anted to dispose of the human rem tle 'bed above as i icate
Date Issued �� ai Registrar of Vital Statistics -2e//4 C•- /
(signature)
gip District Number 5-6 -.S.j Place `"1 &TJv C JQI1 LAS61(S
Sa I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 3 J 1 I Ig Place of Disposition ?KO, 1./ .-.
(address)
(section) (I (lot number))( (grave number)
r Name of Sexton or Person in Charge of Premises , ► J�'it
( lease pant)
Signature (,✓t Title atf it fivi_
(over)
DOH-1555 (02/2004)