Clark Sr, George NEW YORK STATE DEPARTMENT OF HEALTH f A '
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
George A. Clark,Sr Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 20, 2013 72 War or Dates
. Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 34 Central Ave
0 Manner of Death n Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
0 Dr Coppens,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Reter Number
City, Town or Village Queensbury,NY 5657
❑Burial Date Cemetery or Crematory
January 24, 2013 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
N Hold
co
O _ Date Point of
O Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
tl
W
CI" Permission is hereby granted to dispose of the hum n remains described a re as indicated.
Date Issued\ Z2.12_ 0) Registrar of Vital Statisti .G.- 11../
(signature
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition E-j- 0 Place of Disposition Zolii•J 614ei t _.
2 (address)
W
CO
Ce
(section) / (Yo number) (grave number)
p• Name of Sexton or Person in Charge of Premises Illy Slettjir
Z ( lease print)
W Signature s Title Ca MnTU�,tt.L
(over)
DOH-1555(02/2004)