Clarrk, Bruce NEW YORK STATE DEPARTMENT OF HEALTH!' w T7 t(c
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Bruce Francis Clark Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/17/2014 63 years War or Dates
e of Death Hospital, Institution or
it ;CTovxxxX'* XX Glens Falls Street Address Park St Glens Falls, N Y
p ner of Death p4Jatural Cause ❑Accident ❑Homicide ❑Suicide El Undetermined ❑Pending
itJ Circumstances Investigation
tu Medical Certifier Name Title
Robert W. Sponzo M. D.
Address
102 Park Street Glens Falls, Ny 12801
Death Certificate Filed District Number Register Number
i , ToVQXXIXVIUMX Glens Falls 5601 485
Burial Date Cemetery or Crematory
['Entombment10/24/2014 Pine View Cemetery
Address
'Oremation Queensbury, NY 12804
Date Place Removed
114❑Removal and/or Held
and/or Address
Hold
0 Date Point of
05 Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan Funeral Home 01821
Address
11 Alqonkin Street Ticonderoga, N Y
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
t
` Permission is hereby granted to dispose of the human remains described abov as. is ted.
Date Issued 10/20/2014 Registrar of Vital Statistics XL/
signature)
District Number 5601 Place Glens Falls //W/onkfi
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition to, Place of Dispositions 11:14 Crvrior:,,
(address)
tO
(section) / (lot number) (grave number)
Name of Sexton or Person in Charge of Premises Ara,t CNit
�► (please print)
HB Signature ( Title tit.
(over)
DOH-1555 (02/2004)