Clark, Dale Shawn NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Dale Shawn Clark Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/02/2022 56 Years War or Dates
Place of D Hospital,Institution or
W City,Town 6r tillage Glens Falls Street Address Glens Falls Hospital
'p Manner of Death Natural Cause Accident Homicide Suicide El Undetermined ❑Pending
Circumstances Investigation
lU Medical Certifier Name Title
CI Sean Bain MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed itc District Number Register Number
City,Town or Village Glens Falls 5601 2
▪Burial Date Cemetery,Crematory or Facility Name
01/05/2022 Pine View Crematory
Entombment Address
X❑Cremation Queensbury Town,New York
▪Donation
Z• Removal Date Place Removed
and/or and/or Held
H Hold Address
to
0
0- 1-1 Date Point of
U) ❑Transportation
by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
El 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
H Remains are Shipped,If Other than Above
Address
CC
W
0. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/05/2022 Registrar of Vital Statistics Megan Arolin(Electronicail:y Signed)
(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:
�'I
Z Date of Disposition I i t In Place of Disposition "Ea— ds•,
W
2 (address)
W
CO' (section) (lot number) (grave number)
0
`� Ntvl
Name of Sexton or Person in Charge of Premis 1l b
(pleas print)
W Signature Title C 4ilt,
DOH-1555(07/18)p t of 2
Town of Queensbury
Certification of Cremation
IOW Pine View Cemetery and Crematory
This certifies that the remains of: Dale Clark
were cremated on January 6 20 22 at the Pine View
(Month) (Day)
Crematorium, Queensbury, New York, and these are the cremated remains of said body.
Date of Death January , 2 20 22 Age 56
(Month) (Day)
Funeral Home Baker Funeral Home Registered No. 13
(Authorized Signature)
�4
Public Health Law Sec. 4145(2b)
Receipt
Human remains of I delivered on - , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
CLARK
NAME Dale Clark Age: 56
Lot Owner: Nada & Rick Clark
Lot# Huron 27 E Grave# 2
Case: Urn
Died:1 2.22 Interred:1 . 1 1 .2 2
Funeral Home: Baker FH
Cemetery: Pine View