Duell, Charles NEW YORK STATE DEPARTMENT OF HEALTH 4 !Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Charles DueII Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 30, 2011 82 War or Dates
ZPlace of Death Hospital, Institution or
W City, Town or Village Queensbury Street Address The Stanton Nursing & Rehab. Center
Manner of Death 0 Natural Cause Accident � Homicide � Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Roslyn Socolof MD,
Address
100 Broad St Plaza Glens Falls NY 12801
Death Certificate Filed Di tics ytnMrRegister Number
City, Town or Village �� �1
❑Burial Date Cemetery or Crematory
August 1, 2011 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ri Removal and/or Held
and/or Address
F.. Hold
Date Point of
a'❑Transportation Shipment
CO by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
• Address
CC
a" Permission is here y granted to dispose of the human re ai described a vs as indicated.
Date Issued t t ao Registrar of Vital Statistics Gam `-- Q • ( f,—
(signature)
District Number c(>t•S —) Place t 0 c4
I certify that the remains of the decedent identified above were disposed of in acc dance ith this permit on:
w Date of Disposition ii'I-t( Place of Disposition P tb.—_) C,c+�+*e4orr:,
(address)
W
CO' (section) (lot numbe (grave number)
in• Name of Sexton or Pe on in Charge if Premises (i c>>t iir Se 4t4f
' (please print)
Signature —r--/-119-
Title Cn;:il CR-
(over)
DOH-1555 (02/2004)