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Clark, Charles James tt NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Charles James Clark Male Date of Death Age If Veteran of U.S.Armed Forces, 01/16/2022 84 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Moreau Town Street Address 150 Redmond Road,Moreau Town,New York 12831 'p Manner of Death ©Natural Cause ❑Accident ❑Homicide ❑Suicide ElUndetermined ❑Pending V Circumstances Investigation G Medical Certifier Name Title Anne Evans DO Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Moreau 4562 3 ElBurial Date Cemetery,Crematory or Facility Name 01/19/2022 Pine View Crematory El Entombment Address lCremation Queensbury,New York ❑Donation g ❑Removal Date Place Removed and/or and/or Held } Hold Address O O. Date Point of U) ❑Transportation 5 by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan&Denny Funeral Service 01444 Address 94 Saratoga Ave,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 2 Address MC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/19/2022 Registrar of Vital Statistics Leeann ca6e(ECectronica(ySigned) (signature) District Number 4562 Place Moreau, 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 ► I D ZZ Place of Disposition 2 (address) IILI CC W (section) (lot number) (grave number) gName of Sexton or Person in Charge of Premi s ("I� ��Art.t Z (ple a print) /` W Signature 1_ Title cge M�t"t� DOH-1555(07/18)p t of 2 Public Health Law Sec. 4145(2b) A Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#