Clark, Shirley Ann IIWF
#311NEWYORKSTATEDEPARTMENTOFHEALTHBurial - Transit Permit
s
Bureau of Vital Records .. .
Name First Middle Last Sex
Shirley Ann Clark Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/09/2022 85 Years War or Dates
i_ Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
ILI
0 Manner of Death ❑X Natural Cause Accident 0Homicide 0Suicide FlUndetermined Pending
W
U Circumstances Investigation
W Medical Certifier Name Title
O Scott Biasetti MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 262
laBurial Date Cemetery,Crematory or Facility Name
05/12/2022 Pine View Crematory
Entombment Address
ECremation Queensbury Town,New York
Donation
g❑Removal Date Place Removed
and/or and/or Held
F— Hold Address
N
0
O. Date Point of
Transportation Shipment
(Q by Common
Carrier Destination
Disinterment Date Cemetery Address
ElReinterment 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
S2 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/12/2022 Registrar of Vital Statistics !Megan Nolin(E(ectronically Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IH ,� �/
Z Date of Disposition �13 122 Place of Disposition a tL c t '
2 (address)
W
NCC (section) (lot number) (grave number)
8 Name of Sexton or Person in Charge of remises l 't'1
Z (pie se print)
W Signature Title rt ki
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#