Clymer, Martha NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
MARTHA M CLYMER FEMALE
Date of Death Agge If Veteran of U.S. Armed Forces,
08/10/1997 83 years War or Dates /1/
Place of Death Hospital, Institution or
City, Town or Village FORT EDWARD Street Address FORT HUDSON NURSING HOME
Manner of DeathnX Natural Cause 0 Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
THOMAS KANDORA MD
Address
7240 UPPER BROADWAY, FORT EDWARD, NEW YORK
Death Certificate Filed District Number Register Number
City, Town or Village FORT EDWARD 5755 30
Date Cemetery or Crematory
❑Burial 08/13/1997 PINEVIEW CREMATORIUM
Address
FLI Cremation AUEENSBURY, NEW YORK
Date Place Removed
0 Removal and/or Held
••• and/or Address
Hold
Q Date Point of
NTransportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home SINGLETON-HEALY FUNERAL HOME 01773
7
Address
407 BAY ROAD, AUEENSBURY, NEW YORK 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
A. Address
Permission is hereby granted to dispose of the human remains describe �ove As indicated.
Date IssuedOS/12/1997 Registrar of Vital Statistics
(si ature)
District Numbe5755 Place FORT EDWARD
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 /� ��� ���/1�[ �/U
(address)
UJI
W
M (section) (lot rjumbnr (grave number)
Name of Sextorl or Person in Charge of Preppises , ��/ �
g (please print) P
Signature Title O/L� 57/ / f
DOH-1555 (10/89) p. 1 of 2 VS-61