Clothier, Robert L. •
ti
30
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Robert L Clothier Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/22/2021 84 Years War or Dates 1953-57
t. Place of Death Hospital,Institution or
Z City,Town or Village Albany Street Address Albany Medical Center Hospital
'p Manner of Death NI Natural Cause Accident Homicide Suicide El Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
O Arshad Sami MD
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed District Number Register Number
City,Town or Village Albany 0101 0840
EjBurial Date Cemetery,Crematory or Facility Name
03/24/2021 Pineview Crematory
ElEntombment Address
0 Cremation Queensbury Town,New York
Donation
8 El Removal Date Place Removed
and/or and/or Held
pN Hold Address
Q
yLi Transportation Date Point of
El Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterrnent Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
t.. Remains are Shipped,If Other than Above
S Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/23/2021 Registrar of Vital Statistics Danielle S Gillespie(Electronically Signed)
(signature)
District Number 0101 Place Albany, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z A_Date of Disposition 3IZS1l,i Place of Disposition t—
(a dress)
LU
N cc (section/ (lot ber) (grave number)
Name of Sexton or Person in Charge of Premis
Z (p ease prim /
W Signature Title ceVi��i
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 0 14 3 t 5 t
Receipt
Human remains of _ delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#