Charlebois, Gerald -INEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gerald Louis Charlebois Male
Date of Death Age If Veteran of U.S. Armed Forces,
11/05/2011 91 years War or Dates W W 1 1
Place of Death Hospital, Institution or
5 City, Tow il Street Address
A ARAXX Saratoga Springs Wesl H th Care F^cil'
W Manner of Death❑Nptural Cause III Accident El Homicide ❑Suicide H. eetermmecf Pending
Circumstances Investigation
w Medical Certifier Name Title
Rick D. Teetz M. D.
Address
131 Lawrence Street, Saratoga Springs N Y
Death Certificate Filed District Number Register Number
City, TowtkagyilWYX Saratoga springs 4501 469
❑trial Date Cemetery or Crematory
❑Entombment 11/11/2011 Pine View Cemetery
Address
❑Cremation
-Oueensbury N Y
Date Place Removed
Removal and/or Held
and/or
Address
to
0 Date Point of
k0 Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
Queensbury. N Y
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
0
Ili
I" Permission is hereby granted to dispose of the human rem ins de c., ed indica d.
y •
Date Issued 11/07/2011 Registrar of Vital Statistics
(signature)
District Number 4501 Place Saratoga Springs
l
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
IILI Date of Disposition) 1 /1 1 /1 1 Place of Disposition Pine View Cemetery
2 (address)
Ili
ta Erie 4 E 1
CC (section) (lot number) (grave number)
Ci Name of Sexton or Perso in arge of Premises Michael Denier
2 (please print)
Signaturei2 i A, Title superintendent
(over)
DOH-1555 (02/2004)