Loading...
Clum, Thomas NEW YORK STATE DEPARTMENT OF HEALTH `{ \ 7K Vital Records Section Burial - Transit Permit Name First Middle Last Sex Thomas Howard Clum Male ▪ Date of Death Age If Veteran of U.S. Armed Forces, August 24, 2018 69 War or Dates Place of Death Hospital, Institution or iti City, Town or Village Queensbury Street Address 73 Luzerne Road Cr MI Manner of Death LAilviNatural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending U Circumstances Investigation Ui, Medical Certifier Name Title GLENN ANDERSON, M.D Address Moreau Family Health Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village Su 51 ( a, ❑Burial Date Cemetery or Crematory August 27, 2018 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed Removal and/or Held • and/or Address Hold Pine View Crematorium 1.0 Date Point of ❑Transportation Shipment • by Common Destination Carrier ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom } Remains are Shipped, If Other than Above . Address ce W, ci.. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued g- 22I - ao Iy"Registrar of Vital Statistics fix,k it�.--• (signature) District Number j' p i Place ( V c c elS 1—F I certify that the remains of the decedent identified above were ' posed of in accordance with this permit on: ui Date of Disposition 08/27/2018 Place of Disposition Quaker Road Queensbury,NY 12804'42 (address) 7 IX" (section) (lot/ number) (grave number) Name of Sexton or Person in Charge of Premises �Ar, e1n4 (pleas print) Signature /��+ Title lieErV c7✓t- (over) DOH-1555 (02/2004)