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Arnold, Charles Clin NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Charles Clinton Arnold Male Date of Death Age If Veteran of U.S.Armed Forces, 03/26/2020 73 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Johnsburg Town Street Address Elderwood at North Creek `p Manner of Death ©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending V Circumstances Investigation Q Medical Certifier Name Title Madison Zuis NP Address 112 Ski Bowl Rd,Johnsburg Town,New York 12853 Death Certificate Filed District Number Register Number City,Town or Village North Creek 5655 11 ❑Burial Date Cemetery,Crematory or Facility Name 03/27/2020 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York ❑Donation 0 ❑Removal Date Place Removed and/or and/or Held H U) Hold Address O IL Date Point of N ❑Transportation p by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Restra gition Number Name of Funeral Home Alexander Baker Funeral Home 00037 Address 3809 Main St,Warrensburg, New York 12885 Name of Funeral Firm Making Disposition orto Whom p— Remains are Shipped,If Other than Above 2 Address IM W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/27/2020 Registrar of Vital Statistics Xath(een C.Gorak(ECectronicaCCy Signed (signature) District Number 5655 Place North Creek, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 3-Z -20 20 Place of Disposition t�'!� Girz:vxa LU (address) W lZ (section) number/ (grave number/ SName of Sexton or Person in rg P mises �� `G�h `-p4-m(please print) Z W Signature Title DO H-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 013476 Receipt Human remains of ` ` delivered on , 20 Pine View Cemetery Represendni(the funeral home named on burial.permit Official Funeral Directors Reg.or License# '