Satterlee, Clifford -B3
NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Clifford Merrill Satterlee Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/06/2019 1801ears War or Dates Air Force
.. Place of Death Hospital,Institution or
WCity,Town or Village Johnsburg Town Street Address Elderwood at North Creek
to Manner of Death Natural Cause Accident ❑Homicide Suicide Undetermined Pending
VCircumstances Investigation
QW Medical Certifier Name Title
James Hindson MD
Address
112 Ski Bowl Rd,Johnsburg Town,New York 12853
Death Certificate Filed District Number Register Number
City,Town or Village North Creek 5655 46
Burial Date Cemetery,Crematory or Facility Name
11/07/2019 Pine View Crematory
Entombment Address
aCremation Queensbury,New York
❑Donation
OZ Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
O
d Date Point of
N ❑Transportation
by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition orto Whom
p- Remains are Shipped,If Other than Above
Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/07/2019 Registrar of Vital Statistics Kohfeen C Gnralr(E&tron-alTy Srg=4
(signature)
District Number 5655 Place North Creek, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H �
Z Date of Disposition III-) Place of Disposition tom.f pfvn.
W
2 (address)
W
W (section) (lot number) (grave number)
8 Name of Sexton or Person in Charge of Premises Aq-f �«f
Z (p/e a print)
W Signature Title `
DOH-1555(07/18)p 1 of 2
w
Public Health Law Sec. 4145(2b) 013058
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# ;