Sparks, Clifford NEW YORK STATE DEPARTMENT OF HEALTH � i Burial - Trans t Permit
Vital Records Section
Name First Middle Last Sex
Clifford N. Sparks Male
Date of Death Age If Veteran of U.S.Armed Forces,
1„ September 9, 2012 76 War or Dates No
Z Place of Death Hospital, Institution or
W City,Town,or Village Whitehall Street Address Residence
0 Manner of Death El Natural Cause ❑ Accident ❑Homicide ❑Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W H. Peter Dierksen MD
Q Address
275 Route 30 North, Bomoseen Vermont 05732
Death Certificate Filed District Number Register Number 3
City,Town or Village Whitehall y (p
❑Burial Date SEPT. 13, 2012 Cemetery or Crematory
Pineview Crematorium
❑Entombment Address
Cremation Queensbury, NY 12804
Date Place Removed
0 ❑Removal and/or Held
- and/or Address
l' Hold
V) Date Point of
Q ❑Transportation Shipment
E. by Common Destination
0Carrier
Date Cemetery Address
❑Disinterment
❑Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jilison Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
I- Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
IX
W Address
a.
Permission ishereby granted to dispose of the human remains described above as indicated.
/
Date Issued I''11 /a- Registrar of Vital Statistics ��\ f MA-111-thl-
(signature)
District Number 51 LP ID Place Whitehall,New York
P I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition cj-t3'It Place of Disposition Pineview Crematorium
2 (address)
0
d (section) to umber) - (gravesIumber)
ZName of Sexton or Person in Charge f Premises �� t(d G Mrs'' '
W (please print)
Signature � � Title CV mptOZ.
(over)
DOH-1555 (02/2004)