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Capen, Clay 137" NEW YORK STATE DEPARTMENT Gr HEATH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Clay Date of Death Age If Veteran of U.S. Armed Forces, Feb. 13, 2017 66 yrs. War or Dates A/a F- Place of Death I Hospital, Institution or 2 City, Town or Village Fort Ann Street Address 33 Goodsell Lane la lzi Manner of Death ®Natural Cause ❑Accident 0 Homicide 0 Suicide El Undetermined ❑Pending itti Circumstances Investigation iti Medical Certifier Name Title 0 N. BalasnBramawiam MD. N. Address Albany Medical Ctr. New Scotland. Ave. , Albany, NY. Death Certificate Filed District Number Register Number Mili City, Town or Village Fort Ann S 7 S 4 Date Cemetery or Crematory ❑Burial Feb. 15, 2017 PineView Crematorum Address ©Cremation Quaker Rd. , Queensbury, NY. 12804 Date Place Removed Z ❑Removal and/or Held = and/or Address Hold Q Date Point of NQ Transportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number giil Name of Funeral Home Mason Funeral Home 011 1 7 liiiiii Address Rp 18 George St. , P.O. Box 277, Fort Ann, NY. 12827 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Ag Address AC is Permission is hereby granted to dispose of the human rema. -described above' in icated. -/ -(-1 "= Date Issued 2/1 5/1 7 Registrar of Vital Statistics ignat e)(7vcuN �i/ l 2— d —3 District Number .5 7E Place Jo V I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition Z /7 /7 Place of Disposition ,�,-1 e U/ t2>J 6.re,"rule 2 ( / (address) // til N CC (section) (lot nu ber) (grave number) GName of Sexton o ; e�rson i Charge of Premises LA- / ,c�v 1 6c,,,e0 et 4 '. e Zr -j J�--'' (please print) W Signature '_� � 'G Title C"24 /rii, e7-4 hi DOH-1555 (10/89) p. 1 of 2 VS-61