Webster, Charles tir
NYORK STATE DEPARTMENT OF HEALTH Burial _ Transit Permit
l Records Section
Name First Middle Last Sex
Charles Mason Webster Male
iN Date of Death Age If Veteran of U.S. Armed Forces,
07/09/2011 90 years War or Dates wwii
)4 Place of Death Hospital, Institution or
City, Towrsll,44 XX Glens Falls Street Address Glens Falls Hospital
f Manner of Death ��® Nyntural Cause Accident 0 Homicide El Suicide riUndetermined ri Pending
I Circumstances Investigation
0.
iti Medical Certifier Name Title
Fric PilfemPr M D
.Address
100 Park Street Glens Falls, Ny 12801
Death Certificate Filed District Number Register Number
City, TowrkgrOIlrXX Glens Falls 5601 308
.::alB)rial Date Cemetery or Crematory
❑Entornbment 07/13/2011 Pine View Cemetery
Address •
:::: []Cremation Queens bury, NY 12804
Date Place Removed
Z.❑Removal and/or Held
12 and/or Address
f= Hold
- 0 Date Point of
ti Transportation Shipment
G by Common Destination
Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
igg Name of Funeral Home Maynard D. Baker Funeral Home 01149
Address
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
U
L
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/12/2011 Registrar of Vital Statistics L) -,— . L).A 1 -
(signatur
District Number 5601 Place Glens Falls
:::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tiiDate of Disposition 7/13/201/1ace of Disposition Pine View Cemetery
(address)
ILI Hudson Sec. 2 25B 2
tJ
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
Michael Genier
(please print)
44 Signatur ., `' Title Superintendent
(over)
DOH-1555 (02/2004)