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Royael, Clifford Arthur .- t 1C,L,.5 NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records , Name First Middle Last Sex Clifford Arthur Royael Male Date of Death Age If Veteran of US.Armed Forces, 10/27/2023 91 Years War or Dates 1950-1953 ZZ Place of Death Hospital,Institution or City,Town or Village Queensbury Town Street Address 33 Surrey Fields Drive,Queensbury Town,New York 12804 LU p Manner of Death a Natural Cause Accident Homicide 0 Suicide ❑Undetermined ri Pending VCircumstances Investigation LU Medical Certifier Name Title 0 David Cunningham MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 163 RBurial Date Cemetery,Crematory or Facility Name 10/30/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York DDonation OZ❑Removal Date Place Removed and/or and/or Held H Hold Address N 0 iI. Date Point of U)0Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Maynard D Baker Funeral Home 01130 Address 11 Lafayette St,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom i— Remains are Shipped,If Other than Above 2 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/30/2023 Registrar of Vital Statistics Caroline 7fifdegarrfe Barber(ECectronica1TySigned) (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: I- W Date of Disposition III/23 Place of Disposition jriczt�v /�. "41 Pt ilk 2 (addressf IW CC (section) 4 (lot number) (grave number) 8 Name of Sexton or Person in Charge of Premises A•r... .,ti Z (pprint) W Signature L� TitleflatOnt ib✓L DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of 7 ? delivered on , 20 ..' Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# -4''w