Graves, Charles NEW YORK STATE DEPARTMENT OF HEALTH
Vita!Records Section Burial - Transit Permit
Name First Middle Last Sex
Charles Edward Graves Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 11, 2012 72 War or Dates
F- Place of Death Hospital, Institution or
WCity, Town or Village Queensbury Street Address The Stanton Nursing & Rehab. Center
W; Manner of Death J Natural Cause Accident ❑Homicide ❑ Suicide Undetermined El"-I Pending
LI CircumstancesInvestigation
LU Medical Certifier Name Title
CI
Address
Dea • • ate Filed District Number R gister Number
Cit Town or illage ( ,,p 1\� Ti9c J
®Burial Date Cemetery or Crematory
September 15, 2012 Pine View Cemetery
❑Entombment Address
0 Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
z Removal and/or Held
and/or Address
E Hold Pine View Cemetery
( Date Point of
Transportation Shipment
a1 by Common Destination
CI Carrier
ElDisinterment 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
1 Remains are Shipped, If Other than Above
2' Address
CE
LU
CL Permission is hereby granted to dispose of the huma r mains d ribe ve as indicated.
Date Issue ) )c (
(a Registrar of Vital Statistics � �
� ' (signature)
District Numbecj(Qc 1 Place I p, "f..,c c Ca..k • • `.
I certify that the remains of the decedent identified above were disposed of in ac••r,,ance with this permit on:
W Date of Disposition 9/1 5/1 2 Place of Disposition Pine View Cemetery
(address)
LU Hudson Sec. 1 1 6 H 1
Co
(section) (lot number) (grave number)
4 Michael Genier
tn, Name of Sexton or Person in Charge of Premises
Z (please print)
W SignatureIJ9I-AA-A-c,-, Title Superintendent
(over)
DOH-1555 (02/2004)