Clark, Charles H. 111 It i
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NEW YORK STATE DEPARTMENT OF HEALTH , Burial - Transit Permi
Bureau of Vital Records
Name First Middle Last Sex
Charles H.Clark III Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/30/2022 77 Years Waror Dates Marines
i_ Place of Death Hospital,Institution or
W City,Town or Village Wilton Town Street Address 100 Gordon Lane 123,Wilton Town,New York 12831
O Manner of Death Q Natural Cause Accident 0 Homicide Suicide Undetermined El Pending
W Circumstances Investigation
WMedical Certifier Name Title
C John Lukaszewicz MD
Address
101 Ridge Street 2,Glens Falls,New York 12801
Death Certificate Filed Town Of Wilton District Number Register Number
City,Town or Village 4569 41
Burial Date Cemetery,Crematory or Facility Name
08/03/2022 Pine View Crematory
Entombment Address
EICremation Queensbury,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
O. Date Point of
CD Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
Reinterment
Date Cemetery Address
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
1— Remains are Shipped,If Other than Above
2 Address
LE
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/02/2022 Registrar of Vital Statistics Susan Bard-win(ECectronica1ty Signed)
(signature)
District Number 4569 Place Town Of Wilton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
WDate of Disposition 813 I ZZ Place of Disposition 1",:,.q� (. r
2 (address)
W
N (section) �J (lot number (grave number)
0� �fhJ
Name of Sexton or Person in Charge of Premises _ �� L "�°if
Z �ilease print)
w H f�?
Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
1
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#