Randall, Charles 3b6
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Charles E. Randall Male
Date of Death Age If Veteran of U.S. Armed Forces,
08/07/2016 83 years War or Dates Korean
Place of Death Hospital, Institution or
.. City, To k0C RX Saratoga S rin Street Address
t;Ei g gs Sarat°�-a-�Hospital
Manner of Death j,,Natural Cause Accident ❑Homicide ❑Suicide u Undetermined ❑Pending
ILI Circumstances Investigation
in Medical Certifier Name Title
O Carlos A. Ares Md
Address
211 Church St, Saratoga Springs, Ny 12866
a. Death Certificate Filed District Number Register Number
City, T ARX Yk!C7pJiX Saratoga Springs 4501 35.Q
❑Burial Date Cemetery or Crematory
❑Entombment 08/O8/2016 Pineview Crematory
Address
[✓Cremation Queensbury, N Y
Date Place Removed
❑Removal and/or Held
and/or
� Address
Hold
Date Point of
CL
❑Transportation Shipment
2: by Common Destination
iiiii Carrier
El Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
>> Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
Address
7 Sherman Ave, Corinth, New York 12822
DIDil Name of Funeral Firm Making Disposition or to Whom
J . Remains are Shipped, If Other than Above
;'; Address
it
In
fl` Permission is hereby granted to dispose of the human rem ' cri d abre indicated.
Date Issued 08/08/2016 Registrar of Vital Statistics
(signature)
iiii
District Number 41 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ili Date of Disposition ifr/o% Place of Disposition
fmat---f-
W (address)
CO
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises I.,
,�C
.��1. (p/ease print)
Signature A Title tr,tEnepik
(over)
DOH-1555 (02/2004)