Clarke, Joan . IP 1 %‘31
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ,� _ Burial - Transit Permit
Name First Middle Last Sex
-' Joan Clarke Female
{` Date of Death Age If Veteran of U.S. Armed Forces,
August 30, 2015 80 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 23 Wing Street
Manner of Death Q Natural Cause n Accident El Homicide n Suicide Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
.• John Sawyer,MD
Address
9 Carey Road,Queensbury,NY 12804
• Death Certificate Filed District Number Register Number
City, Town or Village 5 G 0 1 i--I -2_6
❑Burial Date Cemetery or Crematory
August 31, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
H Hold
N
O Date Point of
y ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
> Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
• 407 Bay Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
iRemains are Shipped, If Other than Above
Address
• .• Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 8[3 i /15 Registrar of Vital Statistics CAA-ty...p
(signature
District Number coo, Place 6 C iS ra 1 \s y
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 9/2 jig Place of Disposition :K) L -40ra..)
2 (address)
W
CO
Cg (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises /Z'0 3 Dwim
Z (please print)
W Signature ,e Title MionPI
(over)
DOH-1555(02/2004)