Werner, Charles NEW YORK STATE DEPARTMENT OF HEALTH #Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Charles __ Rhinehart Werner Male
Date of Death Age If Veteran of U.S. Armed Forces,
6/8/2018 31 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
pManner of Death n Natural Cause ❑Accident X❑Homicide n Suicide n Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
O Terry Comeau Coroner _
Address
State Rt 9,Lake George NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls Ye,0/ 9/
❑Burial Date Cemetery or Crematory
June 12,2018 Pine View Crematory
❑Entombment Address
IN Cremation Quaker Road,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
Hold
N3 -
—
O Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
Q Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
2 Address
W
a Permission is hereby ranted to dispose of the human remains descr fed as ov as ' i ated.
Date Issued 0 G // 2)/6- Registrar of Vital Statistics
(signature)
District Number 57o/ Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition d IIf f Place of Disposition
W (address)
CO
(section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises S
Z (pease print)
Signature W Title (i OMI-
(over)
DOH-1555(02/2004)