Crandall, Clayton `1 33
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Clayton Crandall Male
Date of Death Age If Vegan of U.S.Armed Forces,
F. November 28, 2018 b "Mar or Dates WW II
Z Place of Death Hospital, Institution or
W City,Town, or Village Street Address Home
G Manner of Death ❑X Natural Cause ❑ Accident ❑ Homicide Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
O Medical Certifier Name Title
W John Lukaszewiche and
0 Address
VA Clinic Broad Street Glens Falls New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village .5'7 (
n Burial Date Cemetery or Crematory
Dec . 3 2018 Pine View Crematorium
❑ Entombment Address
Cremation Town Of Queensbury
Z Date Place Removed
0 E Removal and/or Held
- and/or Address
I' Hold
YI Date Point of
0 ❑Transportation Shipment
d by Common Destination
Ili Carrier
�- Date Cemetery Address
o ❑ Disinterment
Li Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
X• Remains are Shipped, If Other than Above
W Address
O.
Permission is hereby granted to dispose of the human rema s described above as indicated.
Date Issued I/ '.3 O ,c(6/g Registrar of Vital Statistics . .;--��
(signature)
District Number 5/ cR L Place 1Y , OQ -
�,� 4 , 71- �
F I certify that the remains of the decedent identified above were dis $sed of in accordance with this permit on:
W Date of Disposition /f"30-I(d Place of Disposition tya, V;c,,,) GCC•n^1 o"/
2 (address)
W
0
O (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises -TO-In by SVAceiS
W (please print)
Signature Title C,re.rvcit0(
(over)
DOH-15 02/2004)