Clothier, Delbert NEW YORK STATE DEPARTMENT OF HEALTH qq
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Delbert G. Clothier Male
Date of Death Age If Veteran of U.S. Armed Forces,
12/03/2016 76 years War or Dates
.1 , Place of Death Hospital, Institution or
iTi City, TWAIXX'* X Saratoga Springs Street Address SaratogaHospital
0 Manner of Death Q,Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
tu Medical Certifier Name Title
Pedro Ferrando- Ross M ID
Address
211 Church Street, Saratoga Springs
igi Death Certificate Filed District Number Register Number
City, 1-954='Xi x x Saratoga Springs 4501 567
Burial Date Cemetery or Crematory
12/05/2016 Pineview Cremato
: ❑Entombment Address ry
[, Cremation Queensbury, N Y
Date Place Removed
Z Removal and/or Held
❑
and/or
.. Hold Address
0 Date Point of
Il Transportation Shipment
G'1 by Common Destination
iii Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
gi Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
Address
7 Sherman Ave, Corinth, New York 12822
Name of Funeral Firm Making Disposition or to Whom
ti Remains are Shipped, If Other than Above
„ Address
CC
ill
CL
Permission is hereby granted to dispose of the human remained rib abQ as- dicated.
Date Issued 12/05/2016 Registrar of Vital Statistics 4 -
(signature)
District Number 4501 Place Saratoga Springs
`" I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z ILI Date of Disposition IL It, Ix Place of Disposition En4.0,, ✓ erdr et to(a,--..
2 (address)
Ul
t)
M (section) //!! (lot number) (grave number)
ca Name of Sexton or Person in Charge of Premi s (7t, Jnb��r h"
Z (pl se print)
> . Signature Title tirfA}i
(over)
DOH-1555 (02/2004)