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Clugstone, Joel NEW YORK STATE DEPARTMENT OF HEALTH 1 (JO Vital Records Section Burial - Transit Permit . kh Name First Middle Last Sex Joel R. Clugstone Male Date of Death Age If Veteran of U.S. Armed Forces, December 21,2011 56 War or Dates f_, Place of Death Hospital, Institution or Z City, Town or Village Queensbury Street Address 2257 Ridge Road c©= Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending tit Circumstances Investigation w Medical Certifier Name , Title O Mark M.Hoffman Address 420 Glen Street,Glens Falls,NY 12801 1 Death Certificate Filed District Number Re ister Number City, Town or Village Queensbury 5657 (.1C ❑Burial Date Cemetery or Crematory December 22, 2011 Pine View Crematory 0 Entombment Address ©Cremation Quaker Rd., Queensbury,NY 12804 Date Place Removed Z — Removal and/or Held and/or Address H Hold to ' O Date Point of N Transportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander-Baker Funeral Home 00035 ' Address 3809 Main Street,Warrensburg, NY 12885 Name of Funeral Firm Making Disposition or to Whom i-►, Remains are Shipped, If Other than Above • Address Ul Permission is hereby granted to dispose of the human remains described above as,indicated. Date Issued c)� � � 60 I) Registrar of Vital Statistics _ C. �-- (signature) District Number 5657 Place Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition jG nil M( Place of Disposition Pi tVW./ Crv*a{Or61r- W (address) cn ce (section) lot numbeyr (grave number) pName of Sexton or Person in Charg of Premises 71,4(i t„,,tZ (please print) W /AIL , Signature Title CVrwi-eot (over) DOH-1555 (02/2004)