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Clark, Margaret A
• • .‘ ,. 4 1-iy NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Margaret A.Clark Female Date of Death Age If Veteran of U.S.Armed Forces, 10/19/2021 91 Years War or Dates Place of Death Hospital,Institution or W 0- City,Town or Village Fort Ann Town Street Address 5717 State Route 4, Fort Ann Town,New York 12827 Manner of Death ©Natural Cause ❑Accident ElHomicide El Suicide ❑Undetermined 0 Pending Circumstances Investigation W Medical Certifier Name Title 0 Noelle Stevens MD Address 100 Broad Street,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Fort Ann 15754 i /a ❑ Burial Date Cemetery,Crematory or Facility Name 10/20/2021 Pineview Crematorium ElEntombment Address 0 Cremation Queensbury Town,New York 0 Donation Removal Date Place Removed 1.0 and/or and/or Held F y Hold Address Transportation Date Point of by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Mason Funeral Home 01117 Address 18 George St Po Box 277,Fort Ann,New York 12827-0277 Name of Funeral Firm Making Disposition or to Whom fr. Remains are Shipped,If Other than Above Address f O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/20/2021 Registrar of Vital Statistics Barbara J Winchell(Electronically Signed) (signature) District Number 5754 Place Fort Ann, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 1H � WDate of Disposition fe l tj Ili Place of Disposition Z.I.V.r ( per a (address) W CC (section) (iot umber) (grave number) Name of Sexton or Person in Charge of Premiss a ft1IL, ,c("^.,�� (please print SignatureILI J( Title A''*' DOH-1555(07/18)p 1 of 2 0 1. F 0 Public Health Law Sec. 4145(2b) Receipt Human remains of' '` `'� delivered on , 20 Pine View Cemetery Representing the funeral home name4,ort,burial- ermit Official Funeral Directors Reg.or License# ` �f