Clark, Alonzo H ) , 5
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Alonzo H.Clark Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/17/2020 82 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
UJ
0 Manner of Death I1 Natural Cause El Accident 0 Homicide 1=1 Suicide D Undetermined 0 Pending
111
V Circumstances Investigation
N Medical Certifier Name Title
John Quaresima MD G
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City,Town or Village Fort Edward 5755 108
0 Burial Date Cemetery,Crematory or Facility Name
12/19/2020 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury,New York
❑Donation
2 Removal Date Place Removed
11
Q and/or and/or Held
AHold Address
7A Transportation Date Point of
S by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
aReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
E Remains are Shipped,If Other than Above
Address
IU
d Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/19/2020 Registrar of Vital Statistics Aimee Maloney(Thctro all:ySfgned)
(signature)
District Number 5755 Place Fort Edward, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition i, .Jg-,&p2v Place of Disposition A: , (f e ri�) Ct-i 'i. ,, e
W I k �
(addre$/
W
CO (section) (lot number) (grave number)
D Name of Sexton or Person in Charge Premises )�tq Y`h(9 J (,//p di
Z / please print/
W Signature / /�fl�� Title n �.P �f
1
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 11432
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#