Clark, Virginia 177
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Virginia M. Clark Female
-' Date of Death Age If Veteran of U.S. Armed Forces,
March 11,2015 92 War or Dates
t. Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
p° Manner of Death X Natural Cause n Accident ❑Homicide Suicide Undetermined Pending
Ui. Circumstances Investigation
Medical Certifier Name Title
C Suzanne Rayeski MD
Address
3767 Main Street,Warrensburg,NY 12885
Death Certificate Filed District Number Registex Nber
City, Town or Village C/O Glens Falls 5601 /..fum
El Burial Date Cemetery or Crematory
March 17,2015 Pine View Crematory
0 Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z —Removal and/or Held
O —and/or Address
H Hold
Cl)
O Date Point of
N U Transportation Shipment
'p by Common Destination
Carrier
n Disinterment Date Cemetery Address
Li Reinterment Date Cemetery Address
' Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
i . Remains are Shipped, If Other than Above
Address
4l�k'
Permission is hereby granted to dispose of the human remains escrib/,e/ ab indicated.
Date Issued C3/ 20/5 Registrar of Vital Statistics � I"'
(signature)
District Number 5601 Place C/O Glens Falls,NY
I certify that the remains of the decedent identified above were disposedof in accordance with this permit on:
W , ,wl/I Date of Disposition 311811s Place of Disposition fs.+ e ""
W (address)
CO
OC (section) Sot number) (grave number)
pName of Sexton or Person in Charg of Premises ji. Sa,,n#d'
'Z A.
(please print)
Signature Gam" Title Mt.irie-
(over)
DOH-1555 (02/2004)