Clemons, David ( ';
NEW YORK STATE DEPARTMENT OF HEALTH t
Vital Records Section Burial - Transit Permit
`" Name First Middle Last Sex
David B. Clemons Male
'' Date of Death Age If Veteran of U.S. Armed Forces,
f March 7 2015 72 War or Dates
= Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address The Pines Of Glens Falls
Manner of Death n Natural Cause Accident n Homicide ❑Suicide i l Undetermined Pending
Circumstances Investigation
Medical Certifier
1Name Title
Eileen Spinelli,MD
Address
. fl Warren Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
z City, Town or Village Glens Falls,NY 5601 \ a
❑Burial Date Cemetery or Crematory
March 9, 2015 Pine View Crematorium
❑Entombment Address
0 Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
Cl)
O Date Point of
NTransportation Shipment
'p by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
V Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
4 53 Quaker Road, Queensbury,NY 12804
< 1 Name of Funeral Firm Making Disposition or to Whom
1'`; Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3 i q i ( rj Registrar of Vital Statistics WC "'' e ���
(signs re)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were dispose of in accordance with this permit on:
Z DispositionPlace of Disposition ,M,�•,� o w
W Date of 3 it 15' p i
Waddress)
CO
W (section) lot number) (grave number)
QName of Sexton or Person in Charge of Premises ,, 9cvR1-
W A (pl e pn )
Signature L-......_ Title !2Eittp
(over)
DOH-1555(02/2004)