Polzer, Charles _ 4, a
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NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
• Name First Middle Last Sex
Charles G. Poker Male
M,-f Date of Death Age If Veteran of U.S. Armed Forces,
May 29, 2017 99 War or Dates
i' Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Stanton Nursing & Rehab Centre
`z ,3 Manner of Death n Natural Cause ❑Accident ❑Homicide n Suicide n Undetermined n Pending
..
Circumstances Investigation
:{ Medical Certifier Name Title
Suzanne Blood Dr.
Address
152 Sherman Avenue,Queensbury,NY 12804
f. Death Certificate Filed District Number Register Number
• City, Town or Village Queensbury 5657 ) I
❑Burial Date Cemetery or Crematory
May 31, 2017 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
ZO n Removal and/or Held
and/or Address
f" Hold
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O Date Point of
yn Transportation Shipment
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
iiq Name of Funeral Home Regan& Denny Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls,NY 12803
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 re des ' ed abo• _ • ? ?is ed.
Date Issued Le— I abr.-) Registrar of Vital Statistics 11) ,
(signature
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Date of Disposition i/SI 0 Place of Disposition ii?qi ,.w P+l,,,41'a 1'r.•.%
(address)
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W (section) / (loot number) r �. (grave number)
QName of Sexton or Person in Charge of Premises /Z *.j- r. LIAni 7
Z (ple se print)
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!RE i l�l`Si nature Title
(over)
DOH-1555(02/2004)