Clarke, Peter _W YORK STATE DEPARTMENT OF HEALTA is
ital Records Section Burial - Transit Permit
0..: Name First Middle Last Sex
4 07
Peter Nelson Clarke Male
rfr Date of Death Age If Veteran of U.S. Armed Forces,
;;r. October 10, 2014 64 War or Dates
'`'}� Place of Death 1Hospital, Institution or
City, Town or Village Lake George Street Address 34 West Street
Manner of Death X Natural Cause I jAccident I 1Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
' Jonathan Desantis
fir: Address
{ff 156 Quaker Rd,Queensbury,NY 12804
tir Death Certificate Filed District Number Register Number
iii'i:i City, Town or Village Village of Lake George 5620
❑Burial Date Cemetery or Crematory
October 14, 2014 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z
Removal and/or Held
and/or Address
�' Hold
Cl)
O Date Point of
A. Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address`
n Permit Issued to Registration Number
;r Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
f 53 Quaker Road, Queensbury, NY 12804
j;:1 Name of Funeral Firm Making Disposition or to Whom
I
Remains are Shipped, If Other than Above
Address
frr; Permission is hereby granted to dispose of the human re ains described ab ve a 'ndicated.
r r Date Issued /0/ �\�`J
�� ���o�`� Registrar of Vital Statistics
{,r (signature)
. District Number 5620 Place Village of Lake George
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition 16111Niy Place of Disposition �Vu.. C a._
W (address)
Cl)
CL (section) d (lot n�r) (grave number)
Q Name of Sexton or Person in Charge of Premises 4.,�i�
Zplease print)
Signature 417L 4Title Cig Efritot
(over)
DOH-1555(02/2004)