Randolph, Clarence L ' F
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.,NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Clarence L Randolph Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/06/2022 88 Years War or Dates Reserves
ii. Place of Death Hospital,Institution or
W City,Town or Village Queensbury Town Street Address 251 Chestnut Ridge Road,Queensbury Town,New York 12804
W Manner of Death Ei Natural Cause Accident Homicide Suicide Undetermined Pending
I—ICircumstances Investigation
Medical Certifier Name Title
Sonya Blackmer NP
Address
2 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Villag ; '! 5657 167
Burial 'D Cemetery,Crematory or Facility Name
1008/2022 Pine View Crematory
Entombment Address
IICremation Queensbury Town,New York
❑Donation
fl 0Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
CL Date Point of
e Transportation
Q by Common Shipment
Carrier Destination
- Disinterment Date Cemetery Address
Re interment
Date Cemetery Address
' Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
1 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/08/2022 Registrar of Vital Statistics Caroline 9{iCfegarde Barber gCectronicaCCySigned)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition f/I 0 1z Place of Disposition �,'�,V_ 4---
(address)
ILI
Ir (section) {� (lot number) (grave number)
Q Name of Sexton or Person in Charge of Premises �A/tt L -
z (p se print
W Signature 7-P Title (WIN lilt
DOH-1555(07/18)p 1 of 2
i p{ i {, 0
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial ,-..-
Official Funeral Directors Reg. or License#