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Clinch lll, John A 133e NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex John A Clinch III Male Date of Death Age If Veteran of U.S.Armed Forces, 12/22/2020 62 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 111 Aviation Rd,Queensbury Town,New York 12804 `p Manner of Death ©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation al Medical Certifier Name Title Agee!Gillani MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 229 ❑Burial Date Cemetery,Crematory or Facility Name 12/23/2020 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York ❑Donation 0 El Removal Date Place Removed and/or and/or Held Nf- Hold Address 0 O. Date Point of (0 ❑Transportation p by Common Shipment Carrier Destination Date Cemetery Address ❑Disinterment ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/23/2020 Registrar of Vital Statistics Caroline xldegarde Barber(Electronically Signed) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition a_ •-apav Place of Disposition Pi iJ eve,j e f4-4j < 2 (addressr W N (section) (lot num ) (grave number) gName of Sexton or Person in Ch e of Pre is A0-no,if E-r•(.door (please print) W Signature `�1 /•/! Title O ffoi,45- DOH-1555(07/18)p 1 of 2 r._ Public Health Law Sec. 4145(2b) 014326 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#