Clayton, Virginia NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
mi Name First Middle t Sex
Virginia L. Clayton Female
Date of Death Age If Veteran of U.S. Armed Forces,
10/07/2017 85 years War or Dates
j - Place of Death Hospital, Institution or
LU
mown or XDAXilfX Clifton Park Street Address 207 Coburg Village Way
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
ill ta
Circumstances Investigation
la Medical Certifier Name Title
Schlossberg, Howard Physician
Addres
ip 896 Riverview Road, Rexford, NY 12148
iN Death Certificate Filed District Number Register Number
'' XXVTown or wiles Clifton Park 4552 124
OBurial Date Cemetery or Crematory
10/13/2017 Pine View Cemetery
❑Entombment Address
iiin❑Cremation Queensbury, Ny
iiiiiii] Date Place Removed
❑Removal and/or Held
and/or Address
t Hold
#i)
0 Date ' Point of
in Li Transportation Shipment
GS by Common Destination
Carrier
Iiiii❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
: 0
Name of Funeral Home New Comer Funeral &Cremations
w.
Address
iiiiiiT 181 Troy Schenectady Road, Watervliet, Ny 12189
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
IX
ILLI
!" Permission is hereby granted to dispose of the hu r - (-mains d ribe ove as i dic ed.
Mii`` Date Issued 10/10/2017 Registrar of Vital Statis / J _
(signs ure)
ia District Number 4552 Place Clifton Park
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
to Date of Disposition Place of Disposition
(address)
III
ilk
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
(please print)
itil
nii Signature Title
(over)
DOH-1555 (02/2004)