Clements, William NEW YORK STATE DEPARTMENT OF I ALTH` - N # I N '
Vital Records Section Burial - TransitPermit
40
Name First — Middle Last Sex
William H. Clements Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/15/2011 77 years War or Dates
}•• Place of Death Hospital, Institution or
City, TiRr j( Saratoga Springs Street Address Wesley Health Care Center
Manner of Death�d Natural Cause Accident 0 Homicide Suicide Undetermined Pending
i Circumstances Investigation
ut Medical Certifier Name Title
IP Austin Tsai M D
Address
131 Lawrence St., Saratoga Springs, N Y
: Death Certificate Filed District Number Register Number
City, TRIOXIf XibtEKA Saratoga Springs 4501 127
DI Burial Date Cemetery or Crematory
Entombment 03/17/2011 Pineview Crematorium
Address
QCremation Queensbury N Y
Date Place Removed
Z❑Removal and/or Held
and/or Address
0Hold
0 Date Point of
wilL Q Transportation Shipment
5 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00442
Address
7 Sherman Ave, Corinth, New York 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
,'; Address
C
of
F' Permission is hereby granted to dispose of the human remain ri d abop .ndicate
Date Issued 03/16/2011 Registrar of Vital Statistics I"
(signature)
District Number 4501 Place Saratoga Springs
l
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 3- ZI-kI Place of Disposition ghNeU9tt..) 621,K4 or ivy._
2 (address)
ill
C (section) a
(lot number) (grave number)
Name of Sexton orPe son in Charg of Premises f s}�! Stn,.�rCr
Z �/3 (please print)
,. Signature Title CI-E a
(over)
DOH-1555 (02/2004)