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Woodard ,Clarence Thomas Jr. • Wt.' NEW YORK STATE DEPARTMENT OF HEALTH } Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Clarence Thomas Woodard Jr Male Date of Death Age If Veteran of U.S.Armed Forces, 02/09/2022 88 Years War or Dates Korean )I• Place of Death Hospital,Institution or Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc IIJ 0 Manner of Death ©Natural Cause ❑Accident Homicide ❑Suicide ❑Undetermined 0 Pending W 0 Circumstances Investigation G Medical Certifier Name Title Came Miron PA Address 319 Broadway,Fort Edward Town,New York 12828 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 13 Burial Date Cemetery,Crematory or Facility Name 02/10/2022 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury,New York EiDonation Z El Date Date Place Removed and/or and/or Held H Hold Address NO to ❑Transportation Date Point of a by Common Shipment Carrier Destination El Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above "S Address re W Q. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/10/2022 Registrar of Vital Statistics Aimee G lMakoney(E(ectronica1ty Signed) (signature) District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition D-- l j—).2- Place of Disposition p i h v V i LW Cif t ynq Iof)/ ILI a (address) W Q (section) (lot number) (grave number) gName of Sexton or Person in Charge of Premises ' 't Sill,P,y C.c`J►(-`'S Z ( ease prin) W Signature Title Ci 1",cevi4or DOH-1555(07/18)p 1 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#