Monahan, Clarence William NEW YORK STATE DEPARTMENT OF HEALTH S
Bureau of Vital Records BUrld� - Transit ermit
Name First Middle Last Sex
Clarence William Monahan Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/01/2021 49 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Kingsbury Town Street Address 1586 Route 196, Kingsbury Town, New York 12839
W
p Manner of Death ❑ Natural Cause ❑Accident ❑ Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Q John Aiken Coroner
Address
40 Burquist Road,Fort Ann Town,New York 12827
Death Certificate Filed District Number Register Number
City,Town or Village Kingsbury Town 5762 5
❑Burial Date Cemetery,Crematory or Facility Name
02/08/2021 Pine View Crematory
❑Entombment Address
Cremation Queensbury Town,New York
❑Donation
Removal Date Place Removed
and/or and/or Held
FT) Address
O
a Date Point of
U) ❑Transportation
0 by Common Shipment
Carrier Destination
❑Disinterment
Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
Address
W
G" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/04/2021 Registrar of Vital Statistics Cynthia Bardin(E(ectronicallySigned)
(signature)
District Number 5762 Place Kingsbury Town, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition 1,1 Place of Disposition f,..11-- i✓4d/ILI
!�
2 (address)
W
CC N (section) n��`(lot number) (grave number)
0 1.
Name of Sexton or Person in Charge of Pr ises f �^'/�
Z (pleas print)Signature Title (Ilifftel6fl may d
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) -- ' ~Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#