Clarke, Janet Goddette NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle eLast Sex
Janet Goddette Clarke Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/05/2024 82 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 92 McEchron Lane,Queensbury Town, New York 12804
0 Manner of Death El Natural Cause Accident Homicide 0Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
O Anne Evans DO
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 47
I Burial Date Cemetery,Crematory or Facility Name
04/10/2024 Pine View Cemetery
Entombment
_ Address
Cremation Queensbury,New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0 Date Point of
(/)ETransportation Shipment
isby Common
Carrier Destination
rjDisinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/09/2024 Registrar of Vital Statistics Caroline NI klegaree Barber(Electronically Signed)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z •v'l
W Date of Disposition �,)j�. ��,� Place of Disposition ��l ���;}���, `�Q ���c'�151"�S`�I 1�V C � �•��
(address) v
W \1I,rZI Carl \Cti cl)
U) ection/,., (lot number) (grave number)
8 Name of Sexton or Person in Charge of Premi s (—Jr�1'n) ��C ea .►�
Z (please print)
W Signature 60,,k,...c Z. �- Title -�uC—�1 n --ti-)\-
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
c lG r �L delivered on iO 242y, 20
Human remains of / /
77, ?, IL
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License# C Li 4.4 I
CLARKE Lot No. 19 D
Address 92 McEchronLane Queensbury , NY 12804 Section No.
f
Owner Rene E. & Janet G. Clarke ---- Plot Horicon
Date September 17 , 2008
Approx . 67 Superficial ft.
Location Bounded on the North byShaddock, East by Bly & Curley, West by
Vacant and South by Vacant
Corner Postsr_.W ___-Remarks 792-2754
Deed No. (and changes) 3574
Payment Record Paid in full on 9/17/2008 ($1 , 100.00)
Record of Interments VA C 1
14
t _ S
2 1-
4 C D
I t2LEy
w
Form No. 01 '5 `
E
CLARKE
NAME Janet Ckarke Age: 82
Lot Owner: Rene E & Janet G Clarke
Lot# Horicon 1 9D Grave# 2
Case: Concrete
Died: 4.5.2 4 Interred: 4 . 1 0.2 4
Funeral Home: Regan Denny Stafford
Cemetery: Pine View