Wallace, Charlene NEW YORK STATE DEPARTMENT OF HEALTH T ` i if n3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Charlene J. Wallace Female
Date of Death Age If Veteran of U.S. Armed Forces,
::':D: 06/13/2016 97 years War or Dates
h Place of Death Hospital, Institution or
X City, To V Street Address •
Uj
Manner of Death ],Natural Cause Accident O Homicide O Suicide Undetermine O Pending
ILICircumstances Investigation
w Medical Certifier Name Title
0 StPphPn Fishes M D.
Address
100 Medical Park, Suite 208, Malta, NY 12020
Death Certificate Filed District Number Register Number
City, ToMftWitIMX Saratoga Springs n1 278
Ai El Burial Date Cemetery or Crematory
❑Entombment 06/14/2016 view Crematory
Address
O,Eremation Oueensbur . r,1 Y
Date Place Removed
Removal and/or Held
431,❑and/or Address�
Hold
0 Date Point of
clW O Transportation Shipment
a by Common Destination
giii Carrier
O Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
. , Permit Issued to Registration Number
Name of Funeral Home C = • t;-,ere Funeral Home 00448
Mi Address
Sherman Ave, Corinth, New York 12822
: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
c
Lu
Permission is hereby granted to dispose of the human rema.n's`de ri d abfe indicate .
Date Issued 06/14/2016 Registrar of Vital Statistics `~
(signature)
District Number 4501 Place Saratoga Springs
;.: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
11.1• Date of Disposition Gi(S(f(, Place of Disposition POV,,.0' CAL.
l (address)
4/
CC (section) (lot number)QQ (grave number)
• Name of Sexton or Person in Charg of Premises Mt) Jtv*f1
2
(please print)
Signature Title 'l t.,
(over)
DOH-1555 (02/2004)