Smith, Charles NEW YORK STATE DEPARTMENT OF HEALTH ) `
Vital Records Section Burial - Transit Permit
! Name First Middle Last Sex
Charles Henry Smith Male
Date of Death Age If Veteran of U.S. Armed Forces,
09/01 /201 6 95 yrs. War or Dates 1 942-1 945
Place of Death Town of Hospital, Institution or
City, Town or Village Ticonderogatki Street Address 1 6 Hinds Street
0 Manner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
tti Circumstances Investigation
tu Medical Certifier Name Title
Pt Glen Chapman M.D.
Address
P.O. Box 29, Ticonderoga, New York 12883
Ei Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 41
❑Burial Date Cemetery or Crematory
9/09/2016 Pine View Crematory
['Entombment Address
®Cremation Queensbury, New York
Date Place Removed
,.,... El Removal and/or Held
and/or Address
M=' Hold
VA
0 Date Point of
i0 Transportation Shipment
GS by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
<: Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St, Ticonderoga, New York 12883
Wi Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;' Address
tt
LEI
P.` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued°9/0 2/201 6 Registrar of Vital Statistics I. Sew
(si ature)
iN District Number 1 564 Place Town of Ticonderoga
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 9WO, Place of Disposition alive- 4ar`i4.,-
(address)
lit
Cr (section) (lot number (grave number)
Name of Sexton or Person in Charge of remises 6-0- t414
2 please print)
Signature 1( Title ( 1 j' ,
(over)
DOH-1555 (02/2004)