Clark, Carol Elizabeth 4- 31Z
NEW YORK STATE DEPARTMENT OF HEALTH � Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Carol Elizabeth Clark Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/20/2021 83 Years War or Dates
i,. Place of Death Hospital,Institution or
z City,Town or Village Lake George Town Street Address 602 Goggins Road,Lake George Town,New York 12845
W
,p Manner of Death 0 Natural Cause Accident El Homicide El Suicide Ei Undetermined Pending
V Circumstances Investigation
IIJ G Medical Certifier Name Title
Paul Bachman MD
Address
9 Carey Rd,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Lake George 5651 7
Burial Date Cemetery,Crematory or Facility Name
04/21/2021 Pine View Crematory
0 Entombment Address
Cremation Queensbury Town,New York
0 Donation
0 Removal Date Place Removed
and/or and/or Held
- Hold Address
0
a Date Point of
Cl) LI Transportation
Q by Common Shipment
Carrier Destination
0 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
F— Remains are Shipped,If Other than Above
1" Address
CC
d Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/21/2021 Registrar of Vital Statistics Patricia 1 .01ci(inneySchaster(EkctronicalrySigned)
(signature)
District Number 5651 Place Lake George, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z L '1 ( r
l
tU Date of Disposition ��ZZ f Zl Place of Disposition �,u .._, �d,
2 (address)
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Cr tf)
(section) (lo umber) (grave number)
GName of Sexton or Person in Charge of Premises I' I' b L.. ' .AA 1
Z (please prilt)
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Signature �-^ Title ` � �w N1�K
DOH-1555(07/18)p i of 2
1
Public Health Law Sec. 4145(2b) 0 I 7 30
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#