Clement, Ruth NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section d
Name Frustth Harriet Clement Sex
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Date of Death Age If Veteran of U.S.Armed Forces,
November 20, 1993 80 War or Dates
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Z Place of Death Hospital, Institution or
W it Town or Village Saratoga Springs Street Address Saratoga Hospital
0 Manner of Death j�Natural Cause Accident Homicide Suicide Undetermined Pending
W; ill Circumstances Investigation
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Medical Certifier Name Title
p Dr. Kenneth Schwartz MD
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Saratoga Hospital , Saratoca Springs , NY_ 12866
Death Certificate Filed District Number Register N�ber
it Town or Village Saratoga Springs 4501
Date Cemetery or Crematory
❑Burial November 22 1993 Pine Vier.Crematar�um ..
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[�Cremation Address
Tn of Aueensbury, NY 12804
Z Date Place Removed O; Removal and/or Held
F-< and/or Hold ....... ... .... .. ..............:
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Address
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13L Date Point of
n Transportation by Shipment
p Common Carrier
Destination
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Disinterment
Date Cemetery Address
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Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm Carleton Funeral Home Inc. _ _ p931Q
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Address
P.O. Box 67, 68 Main St., Hudson Falls, N.Y. 12839
t-; Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
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Permission is hereby granted to dispose of the human em inescribIedKaan indicated.
Date Issued Registrar of Vital Statistics
(signature)
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition - Place of Disposition
!' (address)
ua
Cl) (section) (lot number) ,l (grave number)
p' Name of Sexton r Person in harge of Premi s
W - (please print) t
Signature Title �' !
DOH-1555 (10/89) p. 1 of 2 VS-61