Clodfelter,Caroll D 1.....0-, 4 6?
NEWYORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle last Sex
Caroll D.Clodfelter Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/12/2022 83 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
aiMannerof Death E3 Natural Cause DAccident El Homicide OSuicide ❑Undetermined ❑Pending
VCircumstances Investigation
WW Medical Certifier Name Title
CI Gamal Khallfa MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
Cit ,Town or Ville 5601 214
Burial Date Cemetery,Crematory or Facility Name
04/18/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Z❑Removal Date Place Removed
0 and/or and/or Held
CA
Hold Address
0
tOd Date Point of
Tran sportation
CI Common Shipment
Carrier Destination
D.
Date Cemetery Address
1 Disinterment
1❑�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
}— Remains are Shipped,If Other than Above
.S Address
CC
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/18/2022 Registrar of Vital Statistics Mvan Aloha(!rctrimua*Sfgntd) •
(signature/
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition NjIg f tL Place of Disposition 4.74 IL. Zfat—L
al (address)
W
fA
8 /section/ // (lot numb (gra K number)
Name of Sexton or Person in Charge of Premises `I�f4 w+Jr{
W a
ease prmSignature Title ���111 1'n(.,I t1iT Z
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#