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Clum, Peter NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Peter Guthrie Clum Male Date of Death Age If Veteran of U.S. Armed Forces, December 6, 2015 71 War or Dates ZPlace of Death Hospital, Institution or W City, Town or Village Fort Edward Street Address Fort Hudson Nursing Center W Manner of Death El Natural Cause n Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation W Medical Certifier Name Title O Philip Gara, M.D. Dr. Address Broadway Fort Edward, NY 12828 Death Certificate Filed I District N ' 65 RegiNumber City, Town or Village ❑ Burial Date Cemetery or Crematory December 8, 2015 Pine View Crematorium 0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z El Removal and/or Held O I I and/or Address H Hold Pine View Crematorium aDate Point of nTransportation I Shipment t/) by Common Destination d 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 H Remains are Shipped, If Other than Above 2 Address W a' Permission is hereb granted to dispose of the human r irls describe ab a as indicated. Date Issued Registrar ofVital Statistics (signatu ) District Number 5165 Place -T_____iat&A att. ECIAAM/d I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: F- 7�rte J� e�.J c--re i&4 r w Date of Disposition 12/08/2015 Place of Disposition Quaker Road Queensbury,NY 12804 (address) W CO (section) (lot number) (grave number) a p Name of Sexton or Person in Ch e of Premises t ."►� �'�'�7 (fie (please print) W Signature 14.;,..4 — Title (Teo,4` ,4-7 04 ( (over) DOH-1555 (02/2004)