Stark, Nora Clementine # 5Z
NEW YORKSTATE DEPARTMENT OF HEALTH #�- Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Nora Clementine Stark Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/11/2021 95 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
0 Manner of Death EI Natural Cause Accident Homicide Suicide LiUndetermined Pending
UCircumstances Investigation
W Medical Certifier Name Title
0 Carrie Miron PA
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City,Town or Village Fort Edward 5755 2
❑Burial Date Cemetery,Crematory or Facility Name
01/15/2021 Pine View Crematory
Entombment Address
ElCremation Queensbury Town,New York
ElDonation
0 Removal Date Place Removed
and/or and/or Held
H Hold Address
O
a Date Point of
U) Li Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
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 01/13/2021 Registrar of Vital Statistics .7imeeMalmney(ElectronicallySigned)
(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:
WDate of Disposition /—/b—a 07 I Place of Disposition �L9,[ e rettlh t�(
2 (address)
W
U)CC (section) (lot number) (grave number)
SName of Sexton or Person in Charge of Premises c—R/46n0Nd tr. C o0
Z (please print)
W Signature Title (}e r
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 014 418
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#