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Howard Sr., Clifford Wayne (2) t (23 NEW YORK STATE DEPARTMENT OF HEALTH _ Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Clifford Wayne Howard Sr. Male Date of Death Age If Veteran of U.S.Armed Forces, 11/21/2020 56 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation 111 p Manner of Death © Natural Cause 0 Accident ❑Homicide ❑Suicide Undetermined Pending W Circumstances Investigation WI Medical Certifier Name Title a Kenneth France MD Address 170 Warren St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 525 Burial Date Cemetery,Crematory or Facility Name 11/24/2020 Pine View Crematory Entombment Address 0 Cremation Queensbury Town,New York Donation Z ❑Removal Date Place Removed and/or and/or Held - Hold Address 0 O. Date Point of to Li Transportation Shipment p by Common Carrier Destination ❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address CC W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/23/2020 Registrar of Vital Statistics Robert Andrew Curtis(Electronically Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition O I1C 170 Place of Disposition g (address) Iw (section) number) (grave number) 4(lot 0 Name of Sexton or Person in Charge o Pr ises f �' (pleas grin (OP lt-101 W Signature Title DOH-1555(07/18)p 1 of 2 f t t O p, N eci (\.1 • z `'a .0 O a> 44\ C) 0 0- v O coi. O at .. P 'd c t tu it Ir) w 1 1 N S It t V t 1 I a. V) at , of µ_ . U it x 3 t 1 '