Clugston, Allan it
NEW YORK STATE DEPARTMENT OF HEALTH • 11 .
Vital Records Section
�' Burial - Transit Perm t
Name First MiddleMiddle M Ltsgston Sex Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/26/2011 81 years War or Dates Yes
-, Place of Death Hospital, Institution or
Z City, Tof 1%IX Schenectady Street Address Ellis Hospital
ILI• Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending
ill Circumstances Investigation
tint Medical Certifier Name Title
a Anthony R lannucillo M D
Add,r2e4ssRosa Rd Ste 382, Schenectady, N Y 12308
Death Certificate Filed District Number RegLs r Number
City, TA MA\NIX-AXX Schenectady 4601 290
['Burial Date Cemetery or Crematory
04/01/2011 Pineview Crematory
0 Entombment Address
❑cremation Queensbury, N Y
•
Date Place Removed
Z Removal and/or Held
2 ❑and/or Address
I.Z. Hold
'I)
O Date Point of
fki ❑Transportation Shipment .
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date ' Cemetery Address
Permit Issued to Registr�ti22U8o Number
Name of Funeral Home Brewer Funeral Home Inc 00
Address .
24 Church Street, Lake Luzerne, N Y 12846
Name of Funeral Firm Making Disposition or to Whom
I Remains are Shipped, If Other than Above
•
2 Address •
OZ.
W
f" Permission is hereby.granted to dispose of the human remai scribed ove as'nd' ated.
Date Issued 03/31/2011 Registrar of Vital Statistics
(signat re)
District Number 4601 Place Schenectady
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
il-
ill Date of Disposition 11-t-t Place of Disposition 'RN U g ew Crov
y r,
2 (address)
ILI 11E (section) A(ti (lot` er) (grave number)
• Name of Sexton or Person in Cha a of Premises i• t e 3 ftAt-lit
2► (please print)
LU
Signature Title CI VArtL62-
(over)
DOH-1555 (02/2004)