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Clain, James A c(3 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First James Middle William Last Sex Male Date of Death Age If Veteran of U.S. Armed Forces, 11/16/2006 46 years War or Dates 1978-82 j-- Place of Death Hospital, Institution or Z City, ToPSPCVIPCX Saratoga Springs Street Address 528 West St a Manner of Death ❑Natural Cause ❑Accident El Homicide El Suicide ri❑Undetermined ©Pending Circumstances Investigation ill Medical Certifier Name Title CI Michael Sikireca M. D. AdcgsIgroad St Waterford N Y Death C T a Filed District Number Register Number City, To 3fV� X Saratoga Springs 4501 461 ❑Burial Date Cemetery or Crematory 11/21/2006 Pine View Crematory ❑Entombment Address ;:;;: Cremation Cueensbury N Y Date Place Removed Z Removal and/or Held 2❑and/or Address� Sly Hold 0 Date Point of Transportation Shipment C by Common Destination Carrier Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Mi Permit Issued to Clifford Funeral Home Registration00931 Number Name of Funeral Home Address Washington St Rutland Vt Oil Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Ui t fi. Permission is hereby granted to dispose of the human remai ,.i - t - r" '''' 'e 11/19/20106 w Date Issued Registrar of Vital Statistics (signature) District Number 4501 Place Saratoga Springs I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: f* Z til Date of Disposition I( /42 j A6 i, Place of Disposition ?,m y t,.?,,v C ram„=, t r 1 w (address) ILI (section) (lot number) (grave number) Q t1 Name of Sexton or Person in Charge of Premises Ck 0 IS hht, z `�// (please print) iii 1 � � ,y( e�Q Signature Ilµ— Title Crtr,+,tfia( (over) DOH-1555 (02/2004)