Salaway, Charles N
(fi
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
rf: Name First Middle Last Sex
CHARLES ROBERT SALAWAY Male
'f: Date of Death Age If Veteran of U.S. Armed Forces,
June 9, 2018 55 War or Dates
.S: Place of Death Hospital, Institution or
• City, Town or Village Moreau Street Address 2 Christie Lane
;" Manner of Death Natural Cause n Accident Homicide n Suicide Undetermined n Pending
;••,' Circumstances Investigation
:_: Medical Certifier Name Title
:•": Patricia Ford, MD
:?. Saratoga SpringsP;dc r ss
1
:: Death Certificate Filed District Number Regis ear Number
fir: City, Town or Village Moreau _ CI.�S(° `
'. ❑Burial Date Cemetery or Crematory
June 15, 2018 Pine View Crematory
❑Entombment Address
cremation Quaker Road, Queensbury, NY
Date Place Removed
z ❑Removal and/or Held
and/or Address
t. Hold
U)
o Date Point of
coTransportation Shipment
p by Common Destination .
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
• r Name of Funeral Home Singleton Sullivan Potter Funeral Home00 yy
Address 407 Bay y Road Queensbury, NY 12804
Y• Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
- Address
r; Permission is hereby granted to dispose of the human remain descr e a ve as indicated.
}ti:
rr. Date Issued O�P1)61 8 Registrar of Vital Statistics (wAcei
(si ature)
* District Number -1�p� Place I��r �, ja \I
l
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z.
319 Date of Disposition 6'Zf h4 Place of Disposition KO.. ',..Tor'
W (address)
(I)
Ce (section) /(lot number) (grave number)
gName of Sexton or Person in Charge of Premises ln; S.^"+tfr
Z (plarase print)
In
Signature L,%` Title (R6Mrti -
(over)
DOH-1555(02/2004)