Clothier, Dale t17o7
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section 1
Name First Middle Last Sex
DALE A. CLOTHIER MALE
. Date of Death Age If Veteran of U.S.Armed Forces,
07/23/2014 53 War or Dates NO
F Place of Death Hospital, Institution
City ,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER HOSPITAL
la
Manner of Death Natural Undetermined Pending
L ® ❑ Accident ❑ Homicide ❑ Suicide ❑ ❑
US Cause Circumstances Investigation
W_
Medical Certifier Name Title
Q GEORGE SINIAPKIN M.D.
Address
604 PALMER AVE. CORINTH, NY 12822
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 1417
Date Cemetery or Crematory
❑ Burial 07/28/2014 PINEVIEW CREMATORY
0 Entombment Address
® Cremation QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
Q ❑ and/or Address
H Hold
CO
Date Point of
11. Transportation Shipment
CO ❑ By Common Destination
Carrier
El Disinterment
Cemetery Address
Disinterment
Date Cemetery Address
0 Reinterment
Permit Issued To Registration Number
"° Name of Funeral Home DENSMORE FUNERAL HOME 00448
Address
7 SHERMAN AVE. CORINTH, NY 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
tea Address
W'
Llr ��
Permission is hereby granted to dispose of the human remains d bed above as indicate
Date 07/25/2014 .A_�
Issued Registrar of Vital Statistics (signature) (
District Number 101 Place City of Albany, NY (/
I certify that the remains�off the Jde�cedent identified above wer disposed of in accor/ nce with this_is permit on:
I- Date of Disposition -028-" 7 Place of Disposition / //rim l ® h'1d ve(
Z pwer
(address)
Ui
C (section) (lot number) (grave number)
W Name of Sexton or n in C rge of Premises5i Q w/ Ai 0
(please print)
Signature fen d TitleCli �'
(over)
DOH-1555 (02/2004)