Joiner, Clinton 11/
NEW YORK STATE DEPARTMENT OF HEALTH �''�
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Clinton Joiner Male
Date of Death Age If Veteran of U.S. Armed Forces,
4, March 2, 2015 69 War or Dates
k Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause 0 Accident El Homicide EjSuicide 1=1Undetermined ri Pending
, Circumstances Investigation
r'a Medical Certifier Name Title
Farhana Kamal, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
Or• City, Town or Village Glens Falls OCT
❑Burial Date Cemetery or Crematory
March 6, 2015 Pine View Crematory
cf, ❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
14
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
` Carrier
Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
may;
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
�r Address
a
Permission is hereby granted to dispose of the human remains de ribed abo.e as indic. ed.
` Date Issued C1.' 0 /5" Registrar of Vital Statistics �y _ Ale ` /?
_ rgnatu )
District Number ..)6,0 ( Place t -C�,-
gl
• I certify that the remains of the decedent identified above were disposed of in accordance wit his permit on:
e Date of Disposition 03/06/2015 Place of Disposition Quaker Road Queensbury,NY 12 4
(address)
r _ (section) /t number) (grave number)
Name of Sexton or Perso in Charge of Premises
r+> a� 5
(ple se print)
Signature ''� Title ( of
(over)
DOH-1555(02/2004)