Clark, Ricky D NEW YORKSTATE DEPARTMENT OF HEALTH - 'f
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Ricky D Clark Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/05/2021 57 Years War or Dates
F., Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
• Manner of Death ❑X Natural Cause ❑Accident Li Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
0 Michael Adams MD
Address
1448 Route 9,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 6
❑Burial Date Cemetery,Crematory or Facility Name
01/07/2021 Pine View Crematory
❑Entombment Address
iCremation Queensbury Town,New York
ElDonation
ZO Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
a Date Point of
M ❑Transportation
Q by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment 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
I... Remains are Shipped,If Other than Above
2 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/06/2021 Registrar of Vital Statistics Rp6ert/IrairewCur&gkaronicafSrgned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition /— / Place of Disposition /p ,oe Lfiee.3 .f �- � t�(
2 (address
W
N (section) (lot number) (grave number)
//
S Name of Sexton or Person in Charge of Pr ises /✓�7 ✓'/C1 E. 0
// (please print)
W Signature Title Lc7Tj 1—
DOH-1555(07/18)p t of 2
}
Public Health Law Sec. 4145(2b) 014 3 8 6
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
/�` Town of Queensbury
Certification of Cremation
Pine View Cemetery and Crematory
This certifies that the remains of: Ricky D. Clark
were cremated on January , 9 20 21 at the Pine View
(Month) (Day)
Crematorium, Queensbury, New York, and these are the cremated remains of said body.
Date of Death January 5 20 20 Age 57
(Month) (Day)
Funeral Home Singleton,Sullivan,Potter Funeral Home Registered No. 24
(Authorized Signature)
Clark
NAME Ricky D. Clark Age: 57
Lot Owner: Kenneth John Lashway
Lot# Uncas Lot 409 # 22 Grave# 1C
Case: Urn
Died: 1 /5/2020 Interred: 8/25/2021
Funeral Home:Singleton Sullivan Potter
Cemetery: Pine View