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Cameron Jr. Clifford A. i NEW YORKSTATE DEPARTMENT OF HEALTH t a Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Clifford A Cameron Jr.. I Male Date of Death Age If Veteran of U.S.Armed Forces, 12/13/2019 64 Years War or Oates 1984-1989 Place of Death Hospital,Institution or W City,Town or Village Lake George Town Street Address 1897 State Route 9 9,Lake George Town,New York 12845 p Manner of Death © Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation WMedical Certifier Name Title Terry Comeau Coroner Address 1400 St Route 9,Lake George Town,New York 12845 Death Certificate Filed District Number Register Number Cit ,Town orVilla a Lake George 5651 7 ❑Burial Date Cemetery,Crematory or Facility Name 12/18/2019 Pine View Crematory ❑Entombment Address X]Cremation Queensbury Town,New York ❑Donation O ❑Removal Date Place Removed and/or and/or Held H Hold Address N 0 a Date Point of N ❑Transportation Shipment jj by Common Carrier Destination ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom IH Remains are Shipped,If Other than Above Address Q W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/16/2019 Registrar of Vital Statistics Deborah,4 Eofey(Efectronicaffy Signed (signature) District Number 5651 Place Lake George, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z �+ ` W Date of Disposition 11119111 Place of Disposition �,. �,, L.a+dCA.— (address) W U) (section) (lot number) (grave number/ 8 Name of Sexton or Person in Charge of Premises Z tp/ se print) W Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 I Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#