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Fordyce, Clifford Dale J w /SIS7 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Clifford Dale Fordyce Male Date of Death Age If Veteran of U.S.Armed Forces, 10/20/2021 74 Years War or Dates Air Force F. Place of Death Hospital,Institution or 111 Z City,Town or Village Lake George Village Street Address 81 Mohican Street#6,Lake George Village,New York 12845 V Manner of Death © Natural Cause Accident Homicide Suicide ❑Undetermined 0 Pending Circumstances Investigation QW Medical Certifier Name Title Douglas Dennett MD Address 101 Ridge Street,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Lake George Village 5620 8 Burial Date Cemetery,Crematory or Facility Name 10/25/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York 0 Donation ❑Removal Date Place Removed F, and/or and/or Held N Hold Address u ❑Transportation Date Point of CI Common Shipment Carrier Destination ElDisinterment Date Cemetery Address 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 Q W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/25/2021 Registrar of Vital Statistics Debra 9 Mcknney(E(ectronica1Ty Signed) (signature) District Number 5620 Place Lake George Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition /OWWIPli,I Place of Disposition ...FIX Pk... �, ,.e.,.._ LU 2 (address) W U) CC (section) (lot number) (grave number) 8 Name of Sexton or Person in Charge of Premises 4,4. . Stii,�►�lfr WZ ' G e print) / Signature / Title 6 "r Xi DOH-1555(07/18)p i of 2 ..i 7315251. 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#