Major, Clifford NEW YORK STATE DEPARTMENT OF HEALTH _ . W ?i 4
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
CLIFFORD A. MAJOR MALE
Date of Death Age If Veteran of U.S. Armed Forces,
OCTOBER 1, 2015 73 War or Dates N/A
1-i Place of Death Hospital, Institution or
City, Town or Village CITY OF PLATTSBURGH Street Address CVPH MEDICAL CENTER
ILI0 Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑ Undetermined ri❑Pending
Ltd Circumstances Investigation
la Medical Certifier Name Title
Q G. RUSZKA MD
Address
PLATTSBURGH, NY
Death Certificate Filed District Number Register Numberx
�City, Town or Village CITY OF PLATTSBURGH 901 4t/
['Burial Date Cemetery or Crematory
❑Entombment OCTOBER 5, 2015 PINE VIEW CREMATORY
Address
X❑Cremation QUEENSBURY, NY
Date Place Removed
❑Removal and/or Held
and/or Address
h= Hold
t/0
0 Date Point of
05❑Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home WILCOX & REGAN 01821
Address
11 ALGONKIN STREET, TICONDEROGA, NY 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
CC
ltt
II` Permission is hereby granted to dispose of the human remains desc - ed a ve as indicate
Date Issued OCT 2, 2015 Registrar of Vital Statistics ;`/
ignature)C
District Number 901 Place CITY OF PLATTSBURGH
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
U Date of Disposition /O J6/ iS Place of Disposition p,re, v,do G re tiA(406 Wirt
2 (address)
1'
cc (section) A (lot number) (grave number)
ci Name of Sexton or Person in C arge of Premises i ii L. StiAw4
2 lease print)
IAA a
Signature Title MeMil7a
(over)
DOH-1555 (02/2004)