Markwith, Charles NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
CHARLES MARKWT'VH Male
Date of Death Age If Veteran of U.S. Armed Forces,
Dec 10, 2017 88 War or Dates Army
i;i4 Place of Death Hospital, Institution or
ZCity, Town or Village Queensbury Street Address 34 Morningside Circle
a Manner of Death pm Natural Cause ❑Accident D Homicide ❑Suicide ❑Undetermined ❑Pending
��.�
W Circumstances Investigation
W Medical Certifier Name Title
C Dr Borgos, MD
Address
Queensbury, NY
D ificate File trict umber RQgister Number
C y, Town Village It Q��,.,s6 \ SCo
logaB .al Date ` Cemetery or Crematory
December 15, 2017 Pine View Cemetery
al['Entombment Address
.>..:❑Cremation Quaker Road, Queensbury, NY
Date Place Removed
Z Removal and/or Held
❑and/or
Address
104
Hold
0 Date Point of
el r-i
Transportation Shipment
0 by Common Destination
12 Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter 01596
! Address
407 Bay Rd Queensbury, NY
iiiIii Name of Funeral Firm Making Disposition or to Whom
1; Remains are Shipped, If Other than Above
2 Address
cr
fl Permission is hereby granted to dispose of the human remainsem described boove as indicated.
Date Issued to I I 61 —) Registrar of Vital Statistics-r f'"D-�q = `'�+-' ci t
(signature)
Niiiiii District Number Place
S CAS � 0 Liz_..„3,, 0-C 0 i,t.s�--r4�
s:; I certify that the remains of the decedent identified above were disposed of in accor an with this permit on:
Pi
1iJ Date of Disposition /a rS t Place of Disposition cap,,
2 1,� '!- (address)
l F 7Js z/
to
rt (section) (lot number) (grave number)
Name of S- •(hn or Person in Charge of Premises
1 ( ase print)
Signature's i ' d Tit
(over)
DOH-1555 (02/2004)