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Cleveland, Wayne H
L # 70(0 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Wayne H Cleveland Male Date of Death Age If Veteran of U.S.Armed Forces, 02/25/2024 88 Years War or Dates 1956-62 t— Place of Death Hospital,Institution or Z City,Town or Village Corinth Town Street Address 332 Angel Road,Corinth Town,New York 12822 W0 Manner of Death Undetermined Pending Natural Cause ❑Accident Homicide Suicide n V Circumstances Investigation W Medical Certifier Name Title 0 Mitchell Forshey PA Address 665 Saratoga Road 100,Gansevoort Hamlet,New York 12831 Death Certificate Filed Town Of Corinth District Number Register Number City,Town or Village 4553 11 Burial Date Cemetery,Crematory or Facility Name 02/27/2024 Pineview Crematory Entombment _ Address ©Cremation Queensbury Town,New York Donation 8-0 Removal Date Place Removed and/or and/or Held ~ Hold Address N 0 Q. Date Point of M❑Transportation p 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 1— 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 02/26/2024 Registrar of Vital Statistics Brenda L Penis(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 Date of Disposition Z(21129 Place of Disposition ryc i,) (1.?";i14-tr2N•— W 2 (address) LU Cl)rc (section) I (lot number) (grave number) 8 Name of Sexton or Person in Charge o 1 sA Print) _si„.�4- Z tU Signature Title (Pc MAW DOH-1555(07/18)p 1 of 2 11 1 fl r 7 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#