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Clark, Elizabeth IMPir NEW YORK STATE DEPARTMENT OF HEE # i Vital Records Section Burial - Transit Permit Name First Middle Last Sex Elizabeth Anne Clark Female Date of Death Age If Veteran of U.S. Armed Forces, March 17, 2011 82 War or Dates Place of Death Hospital, Institution or City, Town or Village Kingsbury Street Address 113 Feeder Street , Manner of Death E Natural Cause ❑ Accident ❑ Homicide ri Suicide n Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title Abhinetri Pandula, Dr. Address 325 Main Street Hudson Falls, NY 12839 De- c e Fide , District Number 5762 Register Number CI , Tow Villa ,�J� (-c.!`7 06 • ❑Burial Date Cemetery or Crematory March 21, 2011 Pine View Crematorium '❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 ❑ Removal Date Place Removed and/or Held and/or Address Hold Date Point of ❑ Transportation Shipment by Common Destination Carrier Disinterment Date Cemetery Address 40 • ❑ Reinterment Date Cemetery Address • Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00276 R= Address <". Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 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 3-18-2011 Registrar of Vital Statistics c rz,,- ( , ^- o (signature) District Number 6762 Place Town of Kingsbury «Y 1 ; I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 3-12'11 Place of Disposition (+.v U►z‘J Ctfir,.s10(%v& (address) ' (section) / (lot number) (grave number) Name of Sexton or Person in Ch ge of Premises L A r 1st'Ai r- nt.46 o:_ )(please pant) Signature �� Title CQe M i O(, (over) DOH-1555 (02/2004)