Cloran, Charles A g77
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Charles A.Cloran Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/29/2021 88 Years War or Dates 1952-1962
Place of Death Hospital,Institution or
Z City,Town or Village Moreau Town Street Address 198 Bluebird Road, Moreau Town,New York 12803
W
'p Manner of Death XI Natural Cause Accident 1:1Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Madison Zuis NP
Address
9 Carey Road,Queensbury Town, New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Moreau 4562 45
❑Burial Date Cemetery,Crematory or Facility Name
10/01/2021 Pine View Crematory
❑Entombment Address
Cremation Queensbury Town,New York
▪Donation
ElRemoval Date Place Removed
and/or and/or Held
H Hold Address
0
d. Date Point of
Cl) 1-1
Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Miller Funeral Home 01199
Address
6357 Nys Rte#30, Indian Lake,New York 12842
Name of Funeral Firm Making Disposition or to Whom
F— Remains are Shipped,If Other than Above
2 Address
Q
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/01/2021 Registrar of Vital Statistics Leeann Mc Cabe(Electronically Signed)
(signature)
District Number 4562 Place Moreau, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition f i)'l I Place of Disposition ith.
2 (address)
W
CC N (section) /J(lot number) (grave number)
aName of Sexton or Person in Charge of Premise li sheL,
(plat*print) ��j
W Signature Title /���0k1"�—
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
a
I
Human remains of , delivered on �� , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# i