Davis, Clifton 5-9 /
NEW YORK STATE DEPARTMENT O.� HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Clifton J. Davis Male
• Date of Death Age If Veteran of U.S. Armed Forces,
August 2,2017 95 War or Dates
-'14;, Place of Death Hospital, Institution or
Z City, Town or Village Warrensburg Street Address Countryside Adult Home
ALI
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
W: Circumstances Investigation
Medical Certifier Name Title
: Bryan Smead MD
Address
Bolton Health Center,Bolton Landing,NY 12814
V Death Certificate Filed District Number Register Number
City, Town or Village Warrensburg 5660 /A
•
❑Burial Date Cemetery or Crematory
❑Entombment August 4, 2017 Pine View Crematory
Address
OX Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
E Hold
O Date Point of
— —
NI j 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 Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
. Remains are Shipped, If Other than Above —
Address
IX
a Permission is hereby granted to dispose of the human re ins desc ibed a ove as in ' ated.
Date Issued 8-3-17 Registrar of Vital Statistics Li i 1( .tf=/r
(signature)
District Number 5660 Place Warrensburg,NY i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Lu Date of Disposition Sr / Place of Disposition ,)v,t,J eerh,,
w (addr ss)
co
cc
(section) (lot number) (grave number)
Q• Name of Sexton or r o in Charge of Premises J t,,, /r /,"' 4
Z (please print)
tu
Signature Title Giz
(over)
DOH-1555 (02/2004)