Manell, Charles /' 11bl
NEW YORK STATE DEPARTMENT OF HEALTH *:--- --ft
Vital Records Section Burial - Transit Permit
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Name First Middle Last Sex
Charles William Manell Male
Date of Death Age If Veteran of U.S.Armed Forces,
1., October 22, 2018 3 S War or Dates
2 Place of Death Hospital, Institution or !. �-
W City,Town,or Village Whitehall Street Address Home o- J /�ee?-
G Manner of Death 0 Natural Cause ❑ Accident ❑Homicide (Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
O Medical Certifier Name Title
W Suzanne Blood Md
C Address
161 Carey Road Queensbury NY
Death Certificate Filed District Number �� Register Number 8
City,Town or Village Whitehall
n Burial Date Cemetery or Crematory
October 25, 2018 Pineview Crematorium
❑ Entombment Address
▪ 0 Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
0 n Removal and/or Held
- and/or Address
I" Hold
0 Date Point of
0 ❑Transportation Shipment
O. by Common Destination
Carrier
Date Cemetery Address
5 ❑Disinterment
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
X
Remains are Shipped, If Other than Above
W Address
O.
Permission is hereby granted to dispose of the human remai described above as indicated.
Date Issued 1 E017.O Registrar of Vital Statistics Lit*(signature)
Place Whitehall,New York
District Number 57�g
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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w Date of Disposition 10/25/2018 Place of Disposition Pineview Crematorium
E (address)
W
N
0 (section) // (lot numb ) (grave number)
D Name of Sexton or Person in Charge of Premises I(r,s v D8^^iit
Z (please print)
W b / ,- ont IRA
Signature Title
(over)
DOH-1555 (02/2004)