Clark, Mildred t \
# 120
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mildred Lillian Clark Female
Date of Death Age ' If Veteran of U.S. Armed Forces,
March 5,2013 I 81 I War or Dates
.. Place of Death Hospital, Institution or
Z City, Town or Village Warrensburg Street Address 14 Oak Street
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p Manner of Death I XI Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
t.)
uw Medical Certifier Name Title
Ci Bryan Smead
Address
Bolton Health Center,Bolton Landing,NY 12814
Death Certificate Filed District Number Register Number
City, Town or Village Warrensburg 5660
❑Burial Date Cemetery or Crematory
I]Entombment March 7,2013 , Pine View Crematory
Address
❑x Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z Removal 1 and/or Held
and/or Address
I' Hold
ta
O Date Point of
yTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
I
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home L 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
CC
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Permission is h reb granted to dispose of the hu • • em;i. describ above as indicated.
Date Issued .� Registrar of Vital St. istics///1j1,(___- ,t,dL `fc---1
(signature)
District Number 5660 Place Warrensburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z U� C
o,
� Date of Disposition '3-i-t3 Place of Disposition ,.t tw ,
W (address)
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O (section) (lot numbers (grave number)
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p Name of Sexton or Person in Char a of Premises ArIs i+r*ti
iZ lease print)
SignatureLI
Title Llli^-114R)(1„
(over)
DOH-1555 (02/2004)