Loading...
Clark, Dennis NEW YORK STATE DEPARTMENT OF HEALTH E 1 # 176 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Dennis Charles Clark Male Date of Death Age If Veteran of U.S. Armed Forces, February 26, 2012 64 War or Dates t-"` Place of Death Hospital, Institution or W; City, Town or Village Glens Falls Street Address 45 South Street Apt 4 O Manner of Death X I l7r1 Natural Cause El Accident Ej Homicide p Suicide ElUndetermined ri Pending LU O Circumstances Investigation al Medical Certifier Name Title Cl Address Death Certificate Filed District Number Register Number City, Town or Village '1/ ❑Burial Date Cemetery or Crematory March 5, 2012 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address E Hold O Date Point of cL ❑Transportation Shipment W by Common Destination CS Carrier ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 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 E Remains are Shipped, If Other than Above 2 Address IX ii. Permission is hereby granted to dispose of the human remains des i d ov s i sA0d. Date Issued a 3�//20j2—Registrar of Vital Statistics - 3 / (signature) District Number 60/ Place 4,.oG , by I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 11,r&L 1i /60-Place of Disposition Ft nl Ug'10-1 60*sor 114-- (address) WCO re', (section) (lot number) (grave number) 0 d; Name of Sexton or Per on in Charge Premises ^r �� r ���' Z �` (p ease print) ! i - • GD.,5NA r eL- Signature Title (over) DOH-1555 (02/2004)