McDonough, Charles Edmund NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Charles Edmund McDonough Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/02/2020 76 Years War or Dates 1961-1966
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death g
I� X❑ Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
0 William Cleaver MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 59
Burial Date Cemetery,Crematory or Facility Name
02/04/2020 Pine View Crematory
Entombment Address
LaiCremation Queensbury Town,New York
Donation
Z Removal Date Place Removed
P and/or and/or Held
~
N Hold Address
O
IL Date Point of
N 0 Transportation Shipment
p by Common
Carrier Destination
ElDisinterment Date Cemetery Address
Reinterment I Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury, New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
W
(L Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/04/2020 Registrar of Vital Statistics V?p6ert,4nge-a,Curt&(Tfectronrcady,iyned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition Z 10 Place of Disposition4�0 n`
LU (address)
W
N (seaion) (lot number) (grave number)
0
0 Name of Sexton or Person in Charge of Premises lrr
(pl se print/Z
W Signature /ar' Title
DOH-1555(o7/18)p i of 2
Public Health Law Sec. 4145(2b) 3 3
r
Receipt
Human remains of ( % delivered on ��` , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#