Muller, Charles NEW YORK STATE DEPARTMENT OF HEALTH - ' ., yf
Vital Records Section Burial - Transit Perm
• ` it
Name First Middle Last Sex
Charles Lance Muller Male
Date of y Death Age If Veteran of U.S.Armed Forces, �rs' w,-'��'
Jul 26, 2018 69 War or Dates l.1
tPlace of Death Hospital, Institution or
itCity, Town or Village Moreau Street Address 3 Skylark Drive
WManner of Death EI Natural Cause � Accident Homicide Q Suicide 0 Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title 14,0
Michael Sikirica,
Address
50 Broad Street Waterford, NY 12188
Death Certificate Filed District Number R r Number
City, Town or Village Moreau C{ aj J
❑Burial Date Cemetery or Crematory
July 30, 2018 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ri Removal and/or Held
• and/or Address
F Hold
U) Date Point of
o Transportation Shipment
by Common Destination
Q Carrier
Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
W
a' Permission is hereby granted to dispose of the humaasus descri ve as indicated.
Date Issued 7/3°iao(Zj Registrar of Vital Statistics f
/signature)
District Number Lt� D-- Place (�YQ J� N-eu 'dKJc
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 07/30/2018 Place of Disposition Quaker Road Queensbury,NY 12804
W2 (address)
CO
Q (section) lot number) (grave number)
Q Name of Sexton or Person in Charge of Pr mises 0. �tvtfttir
W h (please print)
Signature 1, Title tirikrOrlUit
(over)
DOH-1555(02/2004)