Winney , Clarence M Jr. lOr
� ZZ 7
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Clarence M.Winney Jr Male
Date of Death Age It Veteran of U.S.Armed Forces,
03/25/2022 41 Years War or Dates
Plar.e of Death Hospital,Institution or
Z City,[own or Village Hudson Fails Village Street Address 9 Elm Street Apt. 1,Hudson Falls Village,New York 12839
Manner of Death 0 Natural Cause []Accident []Homicide []Suicide nUndeterrnined ❑Pending
W I Cucumstances Investigation
U
W Medical Certifier Name Title
CI John Stoutenburg MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Village Of Hudson Falls District N,r° .firer Register Number
City,sown or Village 5726 19
[]Burial Date Cemetery,Crematory or Facility
03,29/20 2 Pine View Crematorium
[]Entombment Address
0Cremation Queensbury Town,New York
[]Donation
n Removal
Date Place Removed
andjovar and/or Held
• Bold Address
0
tL Date Point of
to n(ransportation
Q by Common Shipment
Carrier Destination
Date Cemetery Address
[]Disinterment
Date Cemetery Address
[]Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name ui Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
_• Address
CC
LU
a.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/28/2022 Registrar of Vital Statistics Cyrrtlri Bun!m/E(a, Sujnv
/sgnatur al
District Number 5726 Place Village Of Hudson Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition 3131 I ZZ Place of Disposition eRw4.. r�vt
(uJiressl
W
N Cr (sc=clion) /UPnumber! (;rove number/
7
Name of Sexton or Person in Charge of Premises 11'4\Ne`"" tt
tiJ Signature Title
DUH-t555(018)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#