Clark, Thomas Allen 6 (,.
NEWYORKSTATEDEPARTMENTOFHEALTH (,
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Thomas Allen Clark Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/15/2022 73 Years War or Dates Marine
ZPlace of Death Hospital,Institution or
City,Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death ❑X Natural Cause Accident 0 Homicide Suicide Undetermined ri Pending
UJ
U Circumstances Investigation
nil Medical Certifier Name Title
Matthew Loftus PA
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 425
Burial Date Cemetery,Crematory or Facility Name
. 08/16/2022 Pine View Crematory
_Entombment Address
,IJCremation Queensbury,New York
DDonation
Z Date Place Removed
oz❑Removal
and/or and/or Held
g Hold Address
Transportation
Date Point of
3 by Common Shipment
Carrier Destination
Date Cemetery Address
DDisinterment
'" Reinterment Date Cemetery Address
J Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
}p, Remains are Shipped,If Other than Above
Address
11,1
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/16/2022 Registrar of Vital Statistics Megan Wolin(E(ectronicafy Signed)
(signature)
District Number 5601 Place City Of Glens Falls
i I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2 Date of Disposition 8)1)1"It Place of Disposition rF,rV Z
2 (address)
W
CC (section) gx (tot number/ (grave number)
Name of Sexton or Person in Charge miser n L iIT
/p/g�se print/
Signature Title �l r ��m �
DOH-1555 With)p t of 2 //
8
4MS 1 C,.P
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#