Clogston, Marc R i- 313
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Marc R.Clogston Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/10/2022 62 Years War or Dates unknown
H Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
W
p Manner of Death ❑X Natural Cause Accident 0 Homicide ESuicide Undetermined El Pending
W Circumstances Investigation
W Medical Certifier Name Title
CI Courtney Diamond NP
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 207
EBurial Date Cemetery,Crematory or Facility Name
04/11/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
a Date Point of
U)ElTransportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
El
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home Inc 00211
Address
24 Church Street PO Box 500, Lake Luzerne,New York 12846
Name of Funeral Firm Making Disposition or to Whom
N Remains are Shipped,If Other than Above
M Address
CC
LU
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/11/2022 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
(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:
I-
Z Date of Disposition 1/-/3-7)ZZ. Place of Disposition /242 y C.44� Z.-re A 4'
UJ
M (address)
W
Cl)CC (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises J c A.✓L (J�r►�Qvh
Z (please print)
W Signature Title L,ce r / d7').2 /'i.,
DOH-1555(07/18)p 1 of 2
Al A
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#