Hernandez Sr., Charles NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Charles J. Hernandez Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 4, 2013 84 War or Dates
Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
C: Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
I:it Medical Certifier Name Title
CI Dr. Sean Bain,
Address
Death Certificate Filed District Number r Register Number
City, Town or Village 5 C7 t ct 5
' ®Burial Date Cemetery or Crematory
May 9, 2013 ST. ALPHONSUS CEMETERY
❑Entombment Address
OCremation Town of Queensbury,NY
Date Place Removed
Z El
Removal and/or Held
and/or Address
E, Hold ST. ALPHONSUS CEMETERY
CA Date Point of
CY
❑Transportation Shipment
VI by Common Destination
E Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than Above
• Address
1
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 5 /TO t . Registrar of Vital Statistics WCA-&4-,.,Q, UJ..n"
` / (signature)
District Number 5 60 1 Place L9.�5 l 1 `S �' y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition S\i"3 Place of Disposition . \ (4 \nc`?S us Q,� >~sb J -` 1-'
(address)
to S1mtt 6r���
(s tioh) (lot number) (grave number)
0 Name of Sexto Person in Charge of Premises VC4 �
(please print)
W
Signature ----- Title rvtcAr•e,b �
(over)
DOH-1555 (02/2004)