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McGuirk, Clara NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Clara A.McGuirk Female Date of Death Age If Veteran of U.S. Armed Forces, 09/22/2017 85 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation Medical Certifier Name Title Thomas Kandora MD Address 319 Broadway,Fort Edward Town,New York 12828 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 42 ❑Burial Date Cemetery or Crematory 09/29/2017 Pine View Crematory ❑Entombment Address ®Cremation Town of Queensbury, New York Date Place Removed 1-1 Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier El Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 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 09/25/2017 Registrar of Vital Statistics Aimee%za oney Ectronictd5,signed- (signature) District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition q/i !n Place of Disposition 4NA J.✓ ti,r.,cAor lio^) (address) (section) , (lot number) (grave number) Name of Sexton or Person in Charge of Premises [ �.� r ,So^4st- (pl se print) Signature Title (s('1=/"tIRibie- (over) DOH-1555 (02/2004)