Barrett, Sr. Clark NEW YORK STATE DEPARTMENT OF HEALTHs II / L
Vital Records Section 1 Burial - Transit Permit
__` Name First Middle Last Sex
£_ Clark Hamilton Barrett Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 14, 2011 55 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address
Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
D. Tucker Slingerland, M.D. Dr.
Address
1448 Route 9
Death Certificate Filed District Number 'Register Number
• , City, Town or Village (1S- n
0 Burial Date Cemetery or Crematory
May 16, 2011 Pine View Crematory
44❑Entombment
Address
,i ®Cremation Quaker Road Queensbury,NY 12804
zIN Date Place Removed
❑ Removal and/or Held
and/or Address
00 Hold
Date Point of
❑Transportation Shipment
s g by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
,:i IIIPermit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01097
- Address
_.,. 136 Main Street, South Glens Falls NY 12803
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 rem
' described abov indicated.
a �L"
Date Issue ,t(� ` }�� Registrar of Vital Statistics G , Ads.--_,
(signature)
District Number'Z-CoSn Place 1
I certify that the remains of the decedent identified above were disposed of in accorda 4 this permit on:
Date of Disposition 05/16/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
• (section)
(lot number (grave number)
a
g t)
,` � Name of Sexton or Per in Char f Premises r•st r .l,it#
(please print)
Signature [ Title CREhMttQ.
(over)
DOH-1555 (02/2004)