Clark, Barbara s
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Barbara P Clark Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/08/2018 81 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital
Manner of Death Ed Natural Cause El Accident 0 Homicide 0 Suicide Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Rodney Ying MD
Address
211 Church St,Saratoga Springs,New York 12866
• Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs 4501 639
OBurial Date Cemetery or Crematory
12/10/2018 Pineview Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
ri Removal and/or Held
and/or Address
r
Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
El Disinterment Date Cemetery Address
4.44; Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/10/2018 Registrar of Vital Statistics Io/in rn Franck(E(ectronica1Cy Signed)
(signature)
District Number 4501 Place Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition)��l6- Place of Disposition � v,t,t,,) (�fvw,, ey
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises Fz-c""t j v,ti
(please print)
Signature � - ._ � Y Title C Ceihr,k o
(over)
DOH-1555 (02/2004)