Reed, Clifford NEW"YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Clifford Theodore Reed Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 11, 2017 80 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 58 Ogden Rd
Manner of Death Natural Cause Ell Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Li Medical Certifier Name Title
Aqeel A. Gillani, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
Ci , Town or Village Queensbury ,
it®Burial Date Cemetery or Crematory
November 15, 2017 Pine View Cemetery
0 Entombment Address
;� 0 Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
1'1 Removal and/or Held
f I and/or Address
Hold
Date Point of
i 'n Transportation Shipment
by Common Destination
Carrier
pi
El Disinterment
Date Cemetery Address
" ❑ Reinterment Date Cemetery Address
.. Permit Issued to Registration Number
o Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
3. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereb granted to dispose of the human r mains described abo e s indicated.
Registrar of Vital Statistics ;
Date Issued l
(signature)
District Numbe ( Place IC --r, r —(. (--)_ i__L__Q__ _...,,,. ._L.,,k_.,
v.,„„
4.4.,
I certify that the remains of the decedent identified above were disposed of in accord ce with t is permit on:
pro Date of Disposition 11/15/2017 Place of Disposition Quaker Road Queensbury,NY 12804
-
address)
- r J
(se " (lot number) (grave number)
Name of S- il.n or Person in Charge of Premises AJ/• . 6dar-
(pl acrint)
Signature/%0 e Titl
(over)
DOH-1555 (02/2004)