Clayberger, Jimmy D. 1100
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jimmy D.Clayberger Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/10/2021 58 Years War or Dates
F Place of Death Hospital,Institution or
Z City,Town or Village Lake George Village Street Address 78 Helen Street, Lake George Village, New York 12845
W Manner of Death ❑X Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
V Circumstances Investigation
W Medical Certifier Name Title
G Paul Bachman MD
Address
9 Carey Rd,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Lake George Village 5620
Burial Date Cemetery,Crematory or Facility Name
11/12/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
0 ❑Removal Date Place Removed
and/or and/or Held
Hold Address
fA
0
d 1-1 Date Point of
Ul ❑Transportation
Q by Common Shipment
Carrier Destination
Date Cemetery Address
El Disinterment
Date Cemetery Address
Reinterment
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
1.. Remains are Shipped,If Other than Above
2 Address
CC
W
0. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/12/2021 Registrar of Vital Statistics Debraf cickinneyglectronicatySrgned)
(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:
2 �
Date of Disposition /�L13-,�v2 I Place of Disposition U ,�i%)e Ihe e4/ 6;�ivf
2 (a dress)
W
CC (section) f (lot number) (grave number)
1`
�
S Name of Sexton or Person in C rge of remis a f i 4c ,✓ 'ed
C. / (please print)
W Signature /�// Title UeV-4 +0r`
DOH-1555(o7/18)p t 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#