Boland,Clyde S. NEW YORKSTATE DEPARTMENT OF HEALTH if 3q3
Burial - Transit Permit
Bureau of Vita[Records
Name First Middle Last Sex
Clyde S.Boland Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/12/2020 53 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
1p Manner of Death IX Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
U Circumstances Investigation
G Medical Certifier Name Title
Jennifer Donovan DO
Address
9 Carey Road,Queensbury Town, New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 171
❑Burial Date Cemetery,Crematory or Facility Name
04/14/2020 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
0 ❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
O
IL Date Point of
U) ❑Transportation
p by Common Shipment
Carrier Destination
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped,If Other than Above
Address
W
W
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/13/2020 Registrar of Vital Statistics WgbertAmlrew Curtis(ECectronicaffy Signer
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
� '7,W Date of Disposition q � 0 Place of Disposition R. C�
LU (address)
W
N (section) (tot number/ (grave number)
GName of Sexton or Person in Charge of Premiss
Z (p/e e print)
W Signature Title
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b) 0 ?- 3
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#