Clark, Gary NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section i • Burial - Transit Permit
Name First Middle Last Sex
Gary Thomas Clark Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 15, 2011 50 War or Dates After 1/31/55
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death❑ Natural Cause X❑ Accident n Homicide n Suicide n Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Tjle
Timothy Murphy, ..--orcner
Address
52 Haviland Ave Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village .5 epp I 1 : Z
0 Burial Date Cemetery or Crematory
March 23, 2011 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
f ❑Transportation Shipment
by Common Destination
C Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01096
Address
S 6c9(7 :i_z. c ,-- f-c%,rfi -di-c,x), , N J 1 ?2.g
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 3 / l g1' / Registrar of Vital Statistics cwCL.— L),:'-ti,e, - "
tt ��, l (signature)
District Number 5 60 ) Place C �nrsfl\ 1�5 �
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 03/23/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) tt (lot numb r) (grave number)
Name of Sexton or Person in Char of Premises ` i`Sk N r- 'sio-ett
(please print)
,= Signature Title ( ►i ct
(over)
DOH-1555 (02/2004)