Charbonneau, Edward t P 73 g
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Edward L.Charbonneau Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/09/2018 88 Years War or Dates 1948-1952
vey
Oil Place of Death Hospital, Institution or
ICity, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death El NaturalCause 0 Accident Ei Homicide 0 Suicide Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Nawed Siddiqui MD
}_,yn Address
100 Park St,Glens Falls,New York iii; Death Certificate Filed District Number Register Number
6 City,Town or Village Glens Falls 5601 430
❑Burial Date Cemetery or Crematory
xnp 09/10/2018 Pine View Crematorium
`}❑Entombment Address
r®Cremation Queensbury, New York
lx Date Place Removed
1 El❑Removal and/or Held
and/or Address
Hold
Date Point of
El Transportation Shipment
by Common Destination
I
Carrier
to Q Disinterment
Date Cemetery Address
77,
Q Renterment
V. Date Cemetery Address
vPermit Issued to Registration Number
I Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141
Address
'o, 9 Pine St,Chestertown,New York 12817
it Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
lei Permission is hereby granted to dispose of the human remains described above as indicated.
ili,, Date Issued 09/10/2018 Registrar of Vital Statistics Wp6ertA Curtis(E(ectronica((y Signed)
W (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 i I t 7-II It Place of Disposition Qy O,,,. �£,,Rto•�.
(address)
(section) (lot number) ` (grave number)
Name of Sexton or Person in Charge of Premises titis j +rr io4Ji�
(plea print)
Signature v"l a Title !i ii141
(over)
DOH-1555 (02/2004)