Cleveland, Claude Jr.i.
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NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last
Sex
Claude J. Cleveland Jr.
I Male
Date of Death
Age
If Veteran of U.S. Armed Forces,
10/26/2019
87 Years
War or Dates Korea
Place of Death
Hospital, Institution or
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City, Town or Village Johnsburg Town
Street Address Elderwood at North Creek
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p
Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending
W
Circumstances Investigation
W
Medical Certifier Name Title
Michael Miles 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
44
Burial
Date Cemetery, Crematory or Facility Name
Entombment
10/29/2019 Pine View Crematory
Address
RI Cremation
Queensbury Town, New York
Donation
Date
—7and/or
Place Removed
OZRemoval
and/or
Held
f-
Hold
Address
N
O
d
Date
Point of
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Transportation
by Common
Shipment
Carrier
Destination
ElDisinterment
Date
Cemetery Address
JEjReinterment
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
I—
Remains are Shipped, If Other than Above
`j•
Address
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a
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/28/2019 Registrar of Vital Statistics Kathleen C Loralr (E&tronicaf Sr wed)
(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:
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Place Disposition Z41PAJn-
Date of Disposition /o I zgit 1 of 49# t4
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2
(address)
W
N
(section) (lot number (gravenumber)
C
Name of Sexton or Person in Charge of Premises �.r
Z
/easas e print)
W
Signature NAT Title
DO H-1555 (o7/18) p 1 of 2
Public Health Law Sec. 4145(2b) 01 ,1?- 3 4
Receipt
Humanremains of �--: t ,_ 0 delivered on
Pine View Cemetery
Official
, 20 `
Representing the funeral home named on burial permit
Funeral Directors Reg. or License # ",W-