Young, Charles NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Pe emit
Name First Middle Last Sex
Charles P. Young Male
Date of Death Age If Veteran of U.S.Armed Forces, NO
1. June 1, 2011 69 War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Glens Falls Street Address 2Stichman Towers
0 Manner of Death X❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W Timothy Murphy Coroner
Q Address
52 Havilan Ave Glens Falls New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5 60,
❑Burial Date Cemetery or Crematory
June 3, 2011 Pine View Crematorium
❑Entombment Address
®Cremation 21 Quaker Road Queensbury New York 12803
Date Place Removed
0 ❑Removal and/or Held
- and/or Address
I" Hold
10 Date Point of
0 ❑Transportation Shipment
a. by Common Destination
!A Carrier
ii Date Cemetery Address
ol. ❑Disinterment
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00897
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
X
W Address
0.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1e 1 2 l i / Registrar of Vital Statistics (,may GV
(sip gna ure)
District Number 5-6 0 0 Place Glens Falls,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z ty 'f /'
w Date of Disposition '4+ /3) ( Place of Disposition I nt V i;'� C 7tTh t U.r$4.",
(address)
W
N
0 (section) Plot n mber) (grave number)
O Name of Sexton or Pe n in Charge f Premises fli r. er .it h n,e(r
2 (pidlase print)
W
Signature Title CR C nt'Srat-
(over)
DOH-1555 (02/2004)