Clothier, Bruce D # Z
NEWYORKSTATEDEPARTMENTOFHEALTH .� Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Bruce D Clothier Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/24/2022 67 Years War or Dates
H Place of Death Hospital,Institution or
WCity,Town or Village Corinth Town Street Address 38 Hollister Road,Corinth Town,New York 12822
p Manner of Death IlNaturalCause Accident El Homicide nSuicide FlUndetermined nPending
W
C.) Circumstances 'Investigation
W Medical Certifier Name Title
Marena Euashachai DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Corinth District Number Register Number
City,Town or Village 4553 7
Burial Date Cemetery,Crematory or Facility Name
® 05/26/2022 Pineview Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
t/) Hold Address
0
d Date Point of
U)❑Transportation
Q by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
�.. Remains are Shipped,If Other than Above
2 Address
CC
W
C' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/25/2022 Registrar of Vital Statistics Brenda L Peris(Electronically Signed)
(signature)
District Number 4553 Place Town Of Corinth
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z p
111
Date of Disposition S�?lo) Zl Place of Disposition -4 ��
(address
W
CC (section) (lot number) (grave number)
0 t 0 Name of Sexton or Person in Charge of Premises i `�
Z /pp#ase print)
W Signature Title tr
DOH-1555(07/18)p 1 of 2
I ., ( . -►
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#
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