Clark, Leah NEW YORK STATE DEPARTMENT OF HEALTH c i.
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Leah Lynn Clark Female
iM Date of Death Age If Veteran of U.S. Armed Forces,
11/12/2014 49 years War or Dates
Place of Death Hospital, Institution or
itIZ 01)0(Xown or X Greenfield Street Address 2025 Rt 9n, Lot 6
a Manner of Death,Natural Cause 0 Accident Homicide 0 Suicide 0 Undetermined Pending
Iii Circumstances Investigation
la Medical Certifier Name Title
Mina Sun Attendiing Physician
Address
463 Saratoga Road, Scotia Ny
Death Certificate Filed District Number Register Number
06)9(Xown or ViDtifila Greenfield 4557 23
['Burial Date Cemetery or Crematory
11/13/2014 Pine View Crematorium
['Entombment Address
[cremation Queensbury, New York
Date Place Removed
❑
Removal and/or Held
and/or
F Address
0
o.
Hold
0. Date Point of
Transportation Shipment
G by Common Destination
giii Carrier
L Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
niiii Permit Issued.to Registration Number
iligii Name of Funeral Home Maynard D. Baker Funeral Home 01130
ei Address
1llafayette St, Queensbury Ny 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address -
Ili
"` Permission is hereby granted to dispose of the human remains described above as indicated.
IN Date Issued 11/13/2014 Registrar of Vital Statistics •
(signature)
gig District Number 4557 Place Greenfield
La I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition it/ii Ili Place of Disposition ',4,i{i.,.,� C+'w(iivt.,
2 (address)
ILI
CC (section) (lot numbe (grave number)
0 Name of Sexton or Person in Charge of Premises de.. zi.... w" f.«.I►.. ,/� ( ase print)
41. Signature "1/ ,--lT Titleile/ e.,
(over)
DOH-1555 (02/2004)