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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Avon H. Clements Male
Date of Death Age If Veteran of U.S. Armed Forces,
02 / 13 / 2018 81 War or Dates 1954 - 1976
,1: Place of Death Hospital, Institution or
WCity, Town or Village Wilton Street Address 312 Northern Pines Road
g Manner of Death®Natural Cause 0 Accident ❑Homicide E Suicide 0 Undetermined 7 Pending
til Circumstances Investigation
la Medical Certifier Name Title
George S. Knapp MD
Address
520 Maple Ave, Saratoga Springs, NY 12866
Death Certificate Filed District Number Register Number
i City, Town or Village Wilton riZ f� /)
DateCemeteryor Crematory" �`
>=Burial
02 / 15 / 2018 Pine View Crematory
i.;8 Entombment Address
Cremation Queensbury, NY
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
iig'Q Disinterment Date Cemetery Address
iNi
Q Renterment Date Cemetery Address
im.EiPermit Issued to Registration Number
kg Name of Funeral Home Compassionate Funeral Care 00364
Address
402 Maple Ave., Saratoga Sp. , NY 12866
giiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ice'
Permission is hereby granted to dispose of the human remains described above as indicated.
ai
Date Issued J1,- Registrar of Vital Statistics 7///al `ljy
/ (signature
District Number�{(;/ Place Wilton , New York
iL I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Uif Date of Dispositions..— " 1 ir Place of Disposition pint, v;-w GruN4C,cy
(address)
ILI
itf
CC (section) (lot number) (grave number)
Q
ci Name of Sexton or Person in Charge of Premises • 3ef mty/ 3Q LA i f GS.
Z � (please print) •
tti
Signature-" Title �r +�QF
(over)
DOH-1555 (02/2004)