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Clark, Deborah Ann NEW YORK STATE DEPAR TMENT OFHEALTH •ILIBurial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Deborah Ann Clark Female Date of Death Age If Veteran of U.S.Armed Forces, 11/21/2023 67 Years War or Dates H Place of Death Hospital,Institution or W City,Town or Village Chester Town Warren Street Address 7233 State Route 9,Chester Town Warren,New York 12817 O Manner of Death El Natural Cause ❑Accident Homicide Suicide Undetermined Pending ILI 0 Circumstances Investigation 0 Medical Certifier Name Title Judy Podziewski NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed Town Of Chester District Number Register Number City,Town or Village 5652 21 BurialE Date Cemetery,Crematory or Facility Name 11/22/2023 Pine Vie Crematorium Entombment Address ©Cremation Queensbury Town,New York Donation o❑Removal Date Place Removed H and/or and/or Held N Hold Address 0 a. Date Point of U)OTransportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Date Cemetery Address p Reinterment Permit Issued to Registration Number Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141 Address 9 Pine St,Chestertown,New York 12817 Name of Funeral Firm Making Disposition or to Whom F Remains are Shipped,If Other than Above 5 Address IX W a' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/21/2023 Registrar of Vital Statistics Windy Conway(EThctronica1ty Signed) (signature) District Number 5652 Place Town Of Chester I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition II 7V�JZ� Place of Disposition ? Ni e t✓,(e,,J �CY-144 4Or 2 (address) W Cl) Q / (section) (lot number) i (grave number) elName of Sexton or Person in Charge o re ises ��+�/�O,�b the Z (please print) tL Signature . , Title f3E'S DOH-1555(07/18)pi of 2 ( :_.r 4.b �� 4a Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named pn burial permit Official Funeral Directors Reg.or License#