Clark, James A k i31LI
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
James A.Clark Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/17/2020 75 Years War or Dates 1963-1965
Place of Death Hospital,Institution or
W City,Town or Village Saratoga Springs Street Address Wesley Health Care Center Inc
Manner of Death ❑X Natural Cause El Accident ❑Homicide ❑Suicide EI Undetermined D Pending
W C.) Circumstances Investigation
W Medical Certifier Name Title
CI Rick Teetz MD
Address
131 Lawrence St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Saratoga Springs 4501 654
❑Burial Date Cemetery,Crematory or Facility Name
12/18/2020 Pine View Crematory
Entombment Address
gCremation Queensbury Town,New York
❑Donation
ZZ El Removal Date Place Removed
and/or and/or Held
Hold Address
0
d 1-1 Date Point of
U) ❑Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
❑Disinterment
Reinterment Date Cemetery Address
•
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care Inc 00364
Address
402 Maple Ave,Saratoga Springs,New York 12866
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/18/2020 Registrar of Vital Statistics ,7olrn PaufTranckgYec(ronica16 SO(d)
(signature)
District Number 4501 Place Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition g-/rf-zDZU Place of Disposition r,e. V; (.4) C rci'w ►—�
(address) —_J
W
N (section) (lot number)) (grave number)
Name of Sexton or Person in arge of Pr mt�es 1�1�7 H1v.N! ��'
Z (please
print)
W Signature c1"t/
Title
DOH-1555(o7/18)p t of 2
Public Health Law Sec. 4145(2b) 014304
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#