Howard Sr, Clifton NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
6 E 66 Clifton Floyd Howard Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 14, 1995 66 War or Dates
Place eath Hospital, Institution or
Cit , Town r Village Kingsbury Street Address Geer Rd.
:;. Manner of Death❑Natural Cause Accident 0 Homicide 0 Suicide Undetermined Pending
% Circumstances Investigation
7.
Medical Certifier Name Title
Donald, Coroner Pushee (Solis MD was pathologist
Address
Box 191 , Salem, NY 12865
Deat ficate Filed District Number Register Number
Cit Tow rVillage Town of kingsbu y 5762 013
Date Cemetery or Crematory
❑Burial October 16, 1995 Pine View Crematorium
® x Address
Cremation Tn of Aueensbury, MY 12804
Date Place Removed
Z❑Removal and/or Held
0 and/or Address
aHold
0 Date Point of
Z.N Q Transportation Shipment
fl by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc. 00310
Address
P.O. Box 67, 68 Rain St., Hudson Falls, N.Y. 12839
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 described above as indicated.
Date Issued 10-16-95 Registrar of Vital Statistics
(signatur
District Number 5762 Place Town of Kingsbury, New York
I certify that the remains of the decedeni identified above were disposed of in accordance with this permit on:
W Date of Disposition/�"`bPlace of Disposition rhfi� r L' ,� �[J
(address)
Uj
tl�
(section) (lot number) ( ave number)
0 Name of Sexton or Person in arge of Prenjises
- (please print)
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61