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DeMarsh, Clifton NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit ermit Name First Middle Last Sex Clifton DeMarsh Male Date of Death Age If Veteran of U.S. Armed Forces, January 24, 2011 46 War or Dates . Place of Death Hospital, Institution or Z City, Town or Village Glens Falls 1 Street Address Glens Falls Hospital pManner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending BS Circumstances Investigation b Medical Certifier Name Title O Richard Leach MD Address 28 Sherman Avenue, Glens Falls,NY 12801 Death Certificate Filed District Numbe5601 1 Register Number City, Town or Village Glens Falls ❑Burial Date j Cemetery or Crematory ❑Entombment January 28, 2011 Pine View Crematorium Address ❑x Cremation Quaker Road, Queensbury, NY 12804 Date I Place Removed Z Removal and/or Held 2 and/or Address H" Hold Cl) O Date Point of u) Transportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton- Healy Funeral Home 01622 Address 407 Bay Road, Queensbury, NY 12804 Name of Funeral Firm Making Disposition or to Whom I Remains are Shipped, If Other than Above _ Address :OG ILI Permission is her by ranted to dispose of the human re ains described a ve as in• cated. Date Issued ©/ �7 / Registrar of Vital Statistics D ' ���o- / � (signature) District Number 5601 Place Glens Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition JRWgit zai( Place of Disposition n.t Ottt,iC6-.1-.4{-0"it# w (address) co r[ (section) f (lot nu er) (grave number) QName of Sexton or Person in Charg of Premises Chr,i'�Z( ,. hni(,}— Z Y" (please print) W Signature l 1„� Title CQ Mfir0g-- (over) DOH-1555(02/2004)