Vanguilder Jr, Clayton •
NEW YORK STATE DEPARTMENT OF HEALTH t 33 i
Vital Records Section Burial - 1 ransit Permit
:':i Name First • Middle Last Sex
Clayton Karl Vanguilder Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
06/05/2013 52 years War or Dates
14 of Death Hospital, Institution or
Cit ow Q5(Y4SlitXX Glens Falls Street Address park st_Jens falls, n y
ta nner of Death❑Natural Cause 0 Accident ❑Homicide El Suicide ❑Undetermined ending
iiiV Circumstances Investigation
;u;i Medical Certifier Name Title
Q Timothy F Murphy Coroner
• Address
52 Haviland Ave Glens Falls, N Y 12801
D _at Certificate Filed District Number Register Number
it owmcj(ilhkfaXX Glens Falls 5601 • 237
Burial iiiDate Cemetery or Crematory
❑Entombment 06/06/2013 Pine View Crematory
V;iiAddress
'pC4,yemation Queensbury, NY •
Date Place Removed
Z Removal and/or Held
pz,❑and/or Address
to Hold
C Date Point of
Transportation Shipment
O by Common Destination
Carrier
Q Disinterment Date Cemetery Address •
Q Reinterment Date • Cemetery Address
Permit Issued to Registration Number
Ilg Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury, N Y 12804
II Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
Permission is hereby granted to dispose of the human remains desc ibed� above • icated.
lig Date Issued 06/06/2013 Registrar of Vital Statistics � t✓
(signature)
District Number 5601 Place Glens Falls y /cat'I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
til Date of Disposition (Di to Place of Disposition 4::: 1 ., ell rrve-
(address)
LU
tfl
IC (section) X_IsiltiremberSt (grave number)
d Name of Sexton or Pers in Charge o Premises �rA
( ease print)
1 - _ r1y
Signature Title 14Z�Y1.
9 C
(over)
•
DOH-1555 (02/2004)