VanKleeck Jr, Clifford NEW YORK STATE DEPARTMENT OF HEALTH T LC
Vital Records Section r 3 Burial - Transit Permit
1
Name First Middle ' Last Sex
Clifford VanKleeck Jr. Male
Date of Death Age If Ve eran of U.S.Armed Forces,
January 18, 2014 61 War or Dates
I ' 'la of Death Hospital, Institution or
W' City, own or Village Glens Falls Street Address Glens Falls Hospital
nner of Death rznu Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
0Circumstances Investigation
W Medical Certifier Name Title
W
David Cunningham, M.D.
Address
3 Irongate Center Glens Falls, NY 12801
D Certificate Filed District Number Register Number
ity, own or Village�j le✓'5 r 3I1 S 5601 3.5
❑Burial Date Cemetery or Crematory
January 27, 2014 Pine Vew Crematorium
❑Entombment Address
®Cremation Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
y and/or Address
Hold
CO Date Point of
a ❑Transportation Shipment
ca by Common Destination
Q Carrier
I: Disinterment Date Cemetery Address
Date Cemetery Address
El Reinterment
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
2 Address
CC
C" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued l 1 2 ) / i`j Registrar of Vital Statistics tL)Q. -' — Wti,, r-c).-"
(signature)
District Number 5601 Place 6 (-e.)./`5 \l S N U
I t
I—: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 01/27/2014 Place of Disposition Queensbury,NY 12804
2 (address)
W
(.0IX (section) A (lot num r) (grave number)
aName of Sexton or Person in harge f Premises ` ,Ld 9VI.
(please print)
W Signature Title C "Q/L
(over)
DOH-1555 (02/2004)