Carleton, Clarence NEW YORK STATE DEPARTMENT OF HEALTH = .. 8 Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
CLARENCE F CARLETON MALE
Date of Death Age If Veteran of U.S.Armed Forces,
06/07/2014 54 War or Dates
Place of Death Hospital, Institution
City,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
Manner of Death Natural Undetermined Pending
❑ Cause ® Accident ❑ Homicide ❑ Suicide ❑ Circumstances ❑ Investigation
Medical Certifier Name Title
N. BALASUBRUMANIAN MD
Address
., r, 112 STATE ST., ALBANY NY 12207
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 1111
Date Cemetery or Crematory
❑ Burial 06/16/2014 PINE VIEW CREMATORY
❑ Entombment Address
® Cremation QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
❑ and/or Address
t— Hold
CO
0 Date Point of
a Transportation Shipment
i2 ❑ By Common Destination
5 Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued To Registration Number
Name of Funeral Home BREWER F.H. INC 00211
Address
24 CHURCH ST., LAKE LUZERNE NY 12846
Name of Funeral Firm Making Disposition or to Whom
5. Remains are Shipped, If Other than Above
Address
0 Permission is hereby granted to dispose of the human remains des ibed above as indi ted.
Date 06/13/2014 --_.fl). Li? ICE L_Registrar of Vital Statistics iT •
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Issued (signature) III
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance wih this permit on:
i"' Date of Disposition (libliq Place of Disposition 4t1).0,0 C� r
ILI (address)
Eil,'
to
0 o. n
(section) (lumber) (grave number)
Z; Name of Sexton or Person in Charge of Premises " JtL
itt' (please print)
Signature / --- Title COCOirkit
(over)
DOH-1555 (02/2004)