Krause, Clarence NEW YORK STATE DEPARTMENT OF HEALTH It I 1 ri
Vital Records Section r Burial - Transit Permit
Name First Middle Last Sex
Clarence Raymond Krause Male
Date of Death Age If Veteran of U.S.Armed Forces,
March 9, 2015 87 War or Dates World War II
Place of Death Hospital, Institution or
w City, Town or Village Queensbury Street Address 88 Boulevard
Manner of Death a Natural Cause Li Accident 0 Homicide Ei Suicide D Undetermined El Pending
Circumstances Investigation
WW, Medical Certifier Name Title
Anthony Petracca MD,
Address •
Three Irongate Center Glens Falls, NY 12801
Dea i Cate Filed D Ni ct er R gi ter Number
Cit , Town of rs/illage ,l -tr,c7 tJc (_v
{ ❑Buna Date Cemetery or Crematory
March 11, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z. El
Removal and/or Held
▪ and/or Address
p Hold
Date Point of
a. 0 Transportation Shipment
0) by Common Destination
O Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
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
21 Address
[L',
Permission is hereby granted to dispose of the human gemains described Move as indicated.
Date Issued �1` (o1.ic Registrar of Vital Statistics
ignature)
District Numbe
L (�c'"1 Place �, ( per/
I certify that the remains of the decedent identified above were disposed of inc.c92.rdance ith this permit on:
Date of Disposition 03/11/2015 DispositionQueensbury,NY�° p Place of Quaker Road Queensbu NY 12804
(address)
',
e (section) // (lot number) (grave number)
gName of Sexton or Person in Charge of Premises �P�. Snit
Z 4 - please print)
at Signature Title iiMeI+rDL
(over)
DOH-1555 (02/2004)