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Tennyson, Charles#0S'� NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Male Charles H. Tennyson Sr. Date of Death Age If Veteran of U.S. Armed Forces, 09/21/2019 77 Years War or Dates Vietnam Place of Death Hospital, Institution or Street Address 187 Stock Farm Road, Chester Town Warren, New York 12817 WCity, Town or Village Chester Town Warren Manner of Death ® Natural Cause � Accident � Homicide � Suicide � Undetermined � Pending `p Circumstances Investigation V W Medical Certifier Name Title Danushan Sooriabalan MD Address 9 Carey Road, Queensbury Town, New York 12804 --7District Death Certificate Filed Number Register Number City, Town or Village Chestertown 5652 12 Burial Date Cemetery, Crematory or Facility Name 09/27/2019 Pine View Crematory ElEntombment Address © Cremation Queensbury Town, New York Donation Z ❑ Removal Date Place Removed 0 and/or Held and/or Hold Address N 0� N Transportation Date Point of Shipment Q by Common Destination Carrier Disinterment Date Cemetery Address Reinterment joI Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander Baker Funeral Home 00037 Address 3809 Main St, Warrensburg, New York 12885 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address cc W C' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/25/2019 Registrar of Vital Statistics Mindy Conway (ECectronicaffy Signed (signature) District Number 5652 Place Chestertown, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ZDate of Disposition L-� ( Place of Disposition " m✓rG(Jni W W (address) W i (section) (lot number) (grave number) aName of Sexton or Person in Charge of Premises Z_ (pl se print) W Signature Title DO H-1555 (07/18) D 1 of 2 Public Health Law Sec. 4145(2b) 012561 Receipt Human remains of delivered on i f ` , 20 Pine View Cemetery Representmg the �eral`6me named o b 41 rmit Official Funeral Directors Reg. or License # / )�