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Clute, Donald James NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Donald James Clute 7 Male Date of Death Age If Veteran of U.S.Armed Forces, 04/22/2020 28 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Hudson Falls Village Street Address 27 Maple Street Apt.4,Hudson Falls Village,New York 12839 Mannerof Death Natural Cause Accident Homicide Suicide Undetermined ©Pending Circumstances Investigation WMedical Certifier Name Title Robert Lemieux Coroner Address 415 Lower Main Street,Hudson Falls Village,New York 12839 Death Certificate Filed District Number Register Number City,Town or Village Hudson Falls Village 5726 10 Burial Date Cemetery,Crematory or Facility Name 04/27/2020 Pine View Crematory Entombment Address X❑Cremation Queensbury Town,New York Donation ZO Removal Date Place Removed and/or and/or Held U)N Hold Address O U. Date Point of to 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 } Remains are Shipped,If Otherthan Above Address UJ 0. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/27/2020 Registrar of Vital Statistics Cyntkia,4 Bardin(ECectronicaCCy Signed) (signature) District Number 5726 Place Hudson Falls Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition tl I Z()Place of Disposition I1.1 (o.— (address) UJ (section) (lot number) (grave number) SName of Sexton or Person in Charge of P mises 41 L A' 441 Z I (p! se print) W Signature Title e'OF ( L DOH-1555(07/18)p 1 of 2 I Public Health Law Sec. 4145(2b) 013632 Receipt Human remains of delivered on 120 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#