Loading...
Clemonos Jr, Earl - It 53 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex AEarl Roland Clemons Jr Male Date of Death Age If Veteran of U.S. Armed Forces, 11/05/2017 68 Years War or Dates }— Place of Death Hospital, Institution or WCity, Town or Village Glens Falls Street Address Glens Falls Hospital © Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title O' Marcille Labban MD '' Address .-; 100 Park St,Glens Falls,New York 12801 ._ Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 568 El Burial Date Cemetery or Crematory [.4. 11/07/2017 Pine View Crematorium , ❑Entombment Address ;''®Cremation Queensbury Town, New York . Date Place Removed d.Z Removal and/or Held H Z and/or Address Hold !0 Date Point of CO❑Transportation Shipment in by Common Destination Carrier Disinterment Date Cemetery Address E Date Cemetery Address Reinterment ii Permit Issued to Registration Number P:,' Name of Funeral Home Carleton Funeral Home Inc 00281 :` Address 68 Main Stpo Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address ILI Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/06/2017 Registrar of Vital Statistics Rp6ertACurtis TCectronicafySigned (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: iii Date of Disposition /J I C1 in Place of Disposition Eta". 1 c1' (address) 1 (section) lot number) (grave number) Name of Sexton or Person in Charge of Premises i li(1-' tr.A,t.. .,. /1 rf (pleAse print) Signature Title _ C l-nMib(L (over) DOH-1555 (02/2004)