Duval, Clifford NEW YORK STATE DEPARTMENT OF HEALTH t 4 4. -7 r_7_
Vital Records Section Burial - Transit Permit
R -4 Name First Middle Last Sex
Clifford Henry Duval Male
Date of Death Age If Veteran of U.S.Armed Forces,
December 21, 2013 91 War or Dates
rF Place of Death Hospital, Institution or
t1r1., City, Town or Village Queensbury Street Address The Stanton Nursing & Rehab. Center
CI Manner of Death a Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W, Medical Certifier Name Title
tj Suzanne M Blood, MD,
s; Address
14 Manor Dr. Queensbury, NY 12804
Deat "Certi sate Filed CD.4strict Number R gister ber
Cit j own or Village � L9 ¶f I
❑Burial f Date Cemetery or Crematory
December 24, 2013 Pine View Crematorium
❑Entombment Address
1 ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal
0 and/or and/or Held
Hold Address
�. St. Mary's Cemetery
Date Point of
a. El Transportation Shipment
01, by Common Destination
in Carrier
0 Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
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
Address
1
WAL
Permission is hpraby_ ranted to dispose of the human r mans describ d above a indicated.
:, Date Issuer_ 13.1 UlSegistrar of Vital Statistics % ra (L,__.
(signature)
District Number cLo c h Place - . C_- -
certify that the remains of the decedent identified above were disposed of in accordance ith th. permit on:
i-=`
iii Date of Disposition 1a z1
p 11}'4't1.3 Place of Disposition ge .tom 64r ,
(address)
ill
ir= (section) (1 number) (grave number)
0 Name of Sexton or Person incharge of emises /Ic)41
�3 � (pleas print)
Signature IL Title ceekvilorroit
(over)
DOH-1555 (02/2004)