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Charlebois, Bernard 21/3 NEW YORK STATE DEPARTMENT OF HEAL Vital Records Section Burial - Transit Permit Name First Middle Last Sex 9' Bernard Ermest Charlebois Male Date of Death Age If V -, of U.S.Armed Forces, 03/19/2018 85 Years .r Dates Place of Death -ospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death©Natural Cause ❑Accident El Homicide Suicide 0 Undetermined ❑Pending Circumstances Investigation Medical Certifier Name - Title Jean Vanauken PA Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 141 ❑Burial Date Cemetery or Crematory 03/21/2018 Pine View Crematory ❑Entombment Address ®Cremation Queensbury Town, New York Date Place Removed Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/20/2018 Registrar of Vital Statistics 4Zp6ertA Curtis(ECectronicalTySigned) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 3 j ti ll g Place of Disposition (address) (section) (lot number)( (grave number) Name of Sexton or Person in Charge of Premises fil,qc S--4I (pse print) Signature Title (over) DOH-1555(02/2004)