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Clemente, David P NEW YORKSTATE DEPARTMENT OF HEALTH Burial- Transit Permit Bureau of Vital Records Name First Middle Last Sex David P Clemente Male Date of Death Age If Veteran of US.Armed Fortes, 04/08/2021 62 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Bolton Town Street Address 35 Padanarun Road,Bolton Town,New York 12814 W Manner of Death Undetermined Pending ©Natural Cause �Accident �Homicide �Suicide W Circumstances Investigation Ui Medical Certifier Name Title Charles Yun MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Bolton Landing 5650 5 Burial Date Cemetery,Crematory or Facility Name 04/10/2021 Pineview Crematory ElEntombment Address 0 Cremation Queensbury Town,New York Donation ❑Removal Date Place Removed and/or and/or Held H Hold Address N 0 Date Point of N ❑Transportation Shipment S by Common Carrier Destination EiDisinterment Date Cemetery Address Reinterment 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 2 Address W n Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/09/2021 Registrar of Vital Statistics Jodi Petteys(Electronically Signed) /signature) District Number 5650 Place Bolton Landing, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition y//-.o2( Place of Disposition ?,2e /address/S W (section) (lot num �ber) (grave number) Name of Sexton or Person in Charg J`of Premises l41//�0b✓ - OrYl f:. Z (please print) W Signature /d, Title OreTZ4--o lJ DOH-1555(07/18)p i of 2 r t r Public Health Law Sec. 4145(2b) 01.v171 7 3 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#