Akley, Clarence f • k, //i/ 6-Z-/YORK STATE DEPARTMENT OF HEALTH C
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Clarence S. Akley Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 16,2015 82 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
a Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
= Circumstances Investigation
ui Medical Certifier Name Title
Address
Death Certificate Filed District Number Register.Number
City, Town or Village Glens Falls 5601
❑Burial Date Cemetery or Crematory
Entombment July 20, 2015 Pine View Crematory
Address
El Cremation 21 Quaker Rd., Queensbury, NY 12804
Date 1 Place Removed
Z Removal and/or Held
and/or Address
H Hold
U) i
O Date Point of
u) Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg, NY 12885
Name of Funeral Firm Making Disposition or to Whom
h Remains are Shipped, If Other than Above
'r Address
tit
Permission is hereby granted to dispose of the human re ains scribed.above
as i • •d.
Date Issued 07 c)D cp/5'- Registrar of Vital Statistics �T 2? 1 e
(signature)
District Number 5601 Place 2;(- - - ee_�% e
I certify that the remains of the decedent identified above were disposed of in accordance wit this permit on:
W Date of Disposition 71z1igs- Place of Disposition it-,, t r .tot,„..-
W (address)
U)
re (section) _ (lot number (grave number)
pr;^Name of Sexton or Person in Charge of Premises ', thptit
Z Q (please print)
W Signature .�(�.... Title nt4A
(over)
DOH-1555 (02/2004)