Clum, Michael NEW YORK STATE DEPARTMENT OF HEALTH r ---.. * 3 3 2.-
Vital Records Section Burial - Transit Permit
4 Name First Middle Last Sex
Michael Raymond Clum Male
Date of Death Age If Veteran of U.S. Armed Forces,
Al April 27, 2016 65 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
bji
Manner of Death El Natural Cause ❑ Accident El Homicide ❑ Suicide ❑ Undetermined Pending
Circumstances Investigation
4 Medical Certifier Name Title
Carrie Miran,
Address
St"- 9 Carey Road Queensbury, NY 12804
Death Certificate Filed District Number Register Register Number
�
City, Town or Village o2o
E 0 Burial Date Cemetery or Crematory
April 28, 2016 Pine View Crematorium
s.0 Entombment
e,,,,i` Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
zriRemoval and/or Held
: and/or Address
Hold
Date Point of
0 Transportation Shipment
by Common Destination
la Carrier
El Disinterment
Date Cemetery Address
0 Reinterment
Date Cemetery Address
'P! Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
S Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
" _: Remains are Shipped, If Other than Above
;° Address
Ul
CL
Permission is hereby granted to dispose of the human r m ' s described ab�ve a ;indicated.
1°1 Date Issued 14'c3)-8-i(p Registrar of Vital Statistics V
�, (si nature)
District NumberSr/55 Place)!cU A. /}� tVGUan-Ci
,: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 04/28/2016 Place of Disposition Quaker Road Queensbury,NY 12804
g
(address)
(section) (lot number) (grave number)
131
Name of Sexton or Person in Charge of P mises �1 of - 5,1400
zi(please print)
W E Signature t Title
(over)
DOH-1555 (02/2004)