Clark, Mary Ann ,-.. 1.-13\1 Clyi
NEWYORKSTATEDEPARTMENTOFHEALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Mary Ann Clark Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/22/2022 82 Years War or Dates
F Place of Death Hospital,Institution or
W City,Town or Village Albany Street Address Albany Medical Center Hospital
p Manner of Death ❑X Natural Cause {]Accident ❑Homicide Suicide Undetermined ❑Pending
U Circumstances Investigation
W Medical Certifier Name Title
CI Donald Tessitore NP
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed City Of Albany District Number Register Number
City,Town or Village 0101 2729
[ ]Burial Date Cemetery,Crematory or Facility Name
11/30/2022 Pine View Crematory
[]Entombment Address
[ ]Cremation Queensbury Town,New York
EiDonation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
a Date Point of
Cl)0Transportation
p by Common Shipment
Carrier Destination
O
Disinterment
Date Cemetery Address
C Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
5 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/25/2022 Registrar of Vital Statistics Dania'Scillespie(Ekctronicall Signet9
(signature)
District Number 0101 Place City Of Albany
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
WDate of Disposition ILI I 1 l2 Place of Disposition ,.,, m, Zit-_,__
2 (address)
W
U)
CC (section) A (lot number) (grave number)
0Name of Sexton or Person in Charge of Premisesr' L (t
Z (p( e print)
W Signature Title l�+ oit'r
DOH-1555(o7/18)p 1 of 2
d 0 A �y -�
fi
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#