Clark, Edith NEW YORK STATE DEPARTMENT OF HEALTH }
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Edith I. Clark Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 30, 2013 79 War or Dates
E-` Place of Death 7�� �/ Hospital, Institution or
Z City, Town or Village t,/-ems J r 1 S Street Address
0 Manner of Death g Natural Cause Accident Homicide n Suicide n Undetermined 1-1 Pending
U Circumstances Investigation
W Medical Certifier Name Title
a Christopher Hoy,MD
Address
Glens Falls,NY 12801
Death Certificate Filed Glens Falls,NY District Number Register�Nnber
City, Town or Village 5601 ((���
❑Burial Date Cemetery or Crematory
October 31, 2013 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZO Removal and/or Held
and/or Address
E" Hold
N
O Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
i—. Remains are Shipped, If Other than Above
Address
A.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued l 0 ( 3 //j$ Registrar of Vital Statistics IJU
tsignatur
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition Place of Disposition
L (address)
co
O (section) (lot number) (grave number)
QName of Sexton or Person in Charge of Premises
Z (please print)
• Signature Title
(over)
DOH-1555(02/2004)