Clay, Michael OZ
NEW YORK STATE DEPARTMENT OF HEALTH ,Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Michael Leon Clay Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 24,2017 78 War or Dates n/a
Place of Death Hospital, Institution or
Z City, Town or Village Saratoga Springs,NY Street Address Home of the Good Shepherd
ILI
p Manner of Death ❑X Natural Cause n Accident Homicide Suicide n Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
O Dr Romel Gobunsuy,MD
Address
Saratoga Springs,NY
Death Certificate Filed District Nu ber Register Nu
City, Town or Village Saratoga Springs,NY SZ
❑Burial Date Cemetery o Crematory
October 27,2017 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
O.
U) n Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
h Remains are Shipped, If Other than Above
2 Address
ft
O.
Permission is hereby g anted to dispose of the human rem ins d c D*ed afve s indica d.
Date Issued 'L 1 Registrar of Vital Statistics
(signature)
District Number Li I Place i 512.,4(4_3
t` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 10 j 30 IQ Place of Disposition f yt,11✓ 0. 0%iiir--
W (address)
U)
0 (section) / (lot number) r (grave number)
pName of Sexton or Person in Charge of Premises t/+�y a
Z (pase print)
LU4 Signature Title ilizoi 0+4vorz_
(over)
DOH-1555(02/2004)