Carlsen, Clarence NEW YORK STATE DEPARTMENT OF HEALTH t. 7 r ti it
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Clarence Carlsen Male
Date of Death Age If Veteran of U.S. Armed Forces,
08/08/2012 77 years War or Dates 1953 - 1955
N Place of Death Hospital, Institution or
Z 1:11City, Tow A/i XX Glens Falls Street Address Glens FallsHospital
▪ Manner o eath Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undeterrmined ❑Pending
�1 Circumstances Investigation
iii Medical Certifier Name Title
David T. Slingerland M D
Address
100 Park St Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, ToweAAA z.VillamXX Glens Falls 5601 376
El Burial Date Cemetery or Crematory
,: DEntombment 08/08/2012 Pine View Crematorium
Address
❑Cemation Queensbury, NY 112804
Date Place Removed
9❑Removal and/or Held
and/or Address
f= Hold
Date Point of
Cti Transportation Shipment
O by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
ig Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
» Address
11 Lafayette Street Queensbury. N Y 12804
iq Name of Funeral Firm Making Disposition or to Whom •
Remains are Shipped, If Other than Above
2 Address
ill
IX
` Permission is hereby granted to dispose of the human remains described above as indicated.
iii Date Issued 08/08/2012 Registrar of Vital Statistics IA)G
rsignate
District Number 5601 Place Glens Falls) N y (4.60I
!-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition B-1-tti Place of Disposition e4 titw 6140Nth-
2 (address)
LU
U
ir (section) - (lot number) (grave number)
ct Name of Sexton or Person in Charge of Premises l't'st ,' .�l«,4it
Z r (please print)
Signature L Title Cnc.pipej,oYL
(over)
DOH-1555 (02/2004)