Clark, Carolyn NEW YORK STATE DEPARTMENT OF HEALTH 1/ T7 6-13
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Carolyn M. Clark , Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 24, 2016 91 War or Dates
Place • •eath Hospital, Institution or
' City, own Medical Certifier Name r Village Granville Street Address The Orchard Nursing Home
Mann Beath 0 Natural Cause Acciden1t n Homicide 0 Suicide
Undetermined Pending
Circumstances Investigation
,j v< Title ccter �k ayes / 0
/04(24 s+cAr_, RA,qo Address .ft f0,4_ / as-<3Z.
Death C ificate Filed District Number Register Number
City, own r Village Granville 5'[5LO E I
2,0❑Burial Date Cemetery or Crematory
July 26, 2016 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
., Removal and/or Held
, I-1 g and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
w; Permit Issued to Registration Number
,, Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
gyName of Funeral Firm Making Disposition or to Whom
m Remains are Shipped, If Other than Above
Address
• Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued_ `i Q5[api� Registrar of Vital Statistics (\LIZ_
r (signature)
W til
▪ District Number 511S 6 Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tt` Date of Disposition 07/26/2016 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) `` (lot numbe (grave number)
Name of Sexton or Person in Charge o Premises
(please print)
,` Signature 4L Title acg2
(over)
DOH-1555 (02/2004)