Clark, Patricia NEW YORK STATE DEPARTMENT OF HEALTH IP(.1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Patricia Jane Clark Female
Date of Death Age If Veteran of U.S.Armed Forces,
March 4, 2013 77 War or Dates
I Place of Death Hospital, Institution or
wCity, Town or Village Queensbury Street Address The Stanton Nursing & Rehab. Center
0 Manner of Death J Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
IliCircumstances Investigation
I Medical Certifier Name Title
Suzanne M Blood, MD,
Address
14 Manor Dr. Queensburj, NY 12804
T Death Certificate Filed District Number R is a umber
City, Town or Village (mac
❑Burial Date Cemetery or Crematory
March 6, 2013 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
p- Hold
_
Date Point of
0 Transportation Shipment
0); by Common Destination
O Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
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
}_- Remains are Shipped, If Other than Above
2 Address
CC
CL Permission is hereby granted to dispose of the human re ai s described abo a as indicated.
Date Issued 3l(9 13013Registrar of Vital Statistics Q C (�
��—> (signatu )
District Numbe (Qc'1 Place G n -R.Q--,,Sb i-t-i
I certify that the remains of the decedent identified above were disposed of in accorda ce with tt permit on:
iii Date of Disposition &-')-ub Place of Disposition u.(Aket Cr ' (s4j1_
W (address)
Cr,' (section) /ii
(lot number) (grave number)
pName of Sexton or Per on in Charge f Premises .tit
Z (pl ase print)
:W' Signature L. Title E'tte001Fr6R-
(over)
DOH-1555 (02/2004)