McClough, Theodore R NEW YORK STATE DEPARTMENT OF HEALTH
BureauBurial - Transit Permit
of Vital Records
Name First Middle Last Sex
Theodore R McClouth Male
Date of Death Age If Veteran of U.S.Armed Forces,
06/05/2022 53 Years War or Dates
�.. Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
'p Manner of Death ❑X Natural Cause IllAccident Homicide []Suicide Undetermined riPending
Circumstances Investigation
W Medical Certifier Name Title
CI Mathew Varughese DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 305
Burial Date Cemetery,Crematory or Facility Name
06/08/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
[]Donation
4❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
d Date • Point of
V)ETransportation
CI Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
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
1— Remains are Shipped,If Other than Above
■a Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/07/2022 Registrar of Vital Statistics Megan Nolin(EfectronicaITy 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:
IH
W Date of Disposition 01171 Place of Disposition
2 (address)
W
N
(C (section) 7,41(lot number) Sou (grave number)
8 Name of Sexton or Person in Charge of Premit �-�' J(plet4print) /ses `
W Signature a Title
` 7/6
MQ��
DOH-1555(o7/i8)p 1 of 2
.•� 1 7 5
Public Health Law Sec. 4145(2b)
Receipt
1 Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#