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Clark, Edmund Lee
. Ll3 -OF I NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Edmund Lee Clark Male Date of Death Age If Veteran of U.S.Armed Forces, 05/19/2023 91 Years War or Dates Airforce F— Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital 'p Manner of Death El Natural Cause ❑Accident 1=1Homicide Suicide Undetermined Pending ✓ Circumstances Investigation G Medical Certifier Name Title Abigail Macomber 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 256 Burial Date Cemetery,Crematory or Facility Name 05/22/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation g❑Removal Date Place Removed and/or and/or Held . Hold Address O tk. Date Point of (/)Dransportation by Common Shipment Carrier Destination ODisinterment Date Cemetery Address 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 p— Remains are Shipped,If Other than Above a Address Q W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/22/2023 Registrar of Vital Statistics Megan Nofin(E(ectronica(ty 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: Date of Disposition SI"t/IV Place of Disposition 47—tV 2 (address) W CC (section) (lot number) (grave number) SName of Sexton or Person in Charge of Premises �" �(^lc Z lease print) l W Signature Title TLt/ DOH-1555(07/18)p 1 of 2 t,1 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#