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Clark, Nancy NEW YORK STATE DEPARTMENT OF HEALTH •, Burial - Transit Permit Vital Records Section Name First Middle Last Sex Nancy L. Clark Female Date of Death Age If Veteran of U.S. Armed Forces, 06/07/2011 _57 War or Dates F- Place of Death Hospital, Institution or w W City, Town or Village Chesterlim Street Address Deceased's Residence C>t Manner of Death❑Natural Cause 0 Accident ii Homicide uicide Undetermined El Pending WCircumstances Investigation W Medical Certifier Om i- Title ," • Ad essr --, �� -- N. rd r d cii-, /tt, R6a(i7Aa r - l �A-� %�f/ 7 Death Certificate Filed District Number.�� Regist r Number Ci Town or Villa e ❑Burial Date Cemery or � •emsematory. J --, 06/10/2011 t .67— 7 /" CT'47q�.-l 0 f'ate' • Entombment Address �i-� J / ©Cremation WOcC (��i 11.�'it (✓ t U-� -J '/ Y .�`� 7i.)--��l Date P ace Removed 7 Z El Removal and/or Held O and/or Address F. Hold CO Date Point of a. ID Transportation Shipment CO by Common Destination 0 Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address — Permit Issued to Registration Number Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00134 Address 9 Pine St I P.O. Box 455 Chestertown NY 12817 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped, If Other than Above 2 Address CC W O. Permission is hereby granted to dispose of the h an ains describ a• •ye asgndicated. Date Issued • 1-r O:\ Registrar of Vital Statistic .s_." tZ\` , SDistrict Number 6 rj a, Place fQ"iGv`/ 7.) (i/' —C`/�`° - ✓6ul1 �- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: � LDate of Disposition --IO`k` Place of Disposition P'"1l.)«,..) C`""`tt°'gv"r 2 (address) W 0re (section) (lot num (grave number) 4'- p ii— Name of Sexton or i-rson in Charge f Premises � ° �' �`^"� Z t (please print) W Signature t� / Title fh k I �t Q�— I (over) DOH-1555 (02/2004)