McCue, Charlotte t. t P' 532
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
-rj1 Name First Middle Last Sex
f; Charlotte Morgan McCue Female
:rj: Date of Death Age If Veteran of U.S. Armed Forces,
f July 25, 2016 8 War or Dates n/a
' Place of Death
i Hospital, Institution or
City, Town or Village Lake George Street Address Off Cramer Point, Lake George, NY
Manner of Death X Natural Cause I I Accident [Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
r Michael Sikiirica,MD
r' Address
{f Waterford,NY
Death Certificate Filed District Number Register Number
r;' Civx. ty, Town or Village Lake George, NY
❑Burial Date Cemetery or Crematory
❑Entombment July 29, 2016 Pine View Crematorium
Address
❑x Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F Hold
N
O Date ! Point of
j Transportation Shipment
3 by Common Destination
Carrier
n Disinterment Date 1 Cemetery Address
Reinterment Date Cemetery Address
e�� Permit Issued to Registration Number
fir: Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Y:; Address
` :r 53 Quaker Road, Queensbury, NY 12804
::r Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
. : Permission is hereby granted to dispose of the human re 'ns des ibed above as indicated.
.r ,�r Date Issued 7/ )/(p Registrar of Vital Statistics
:::r (signature)
District Number s7 S( Place 69i p e Lit
I certify that the remains of the decedent identified above were dispgied of in accordance with this permit on:
Z
w Date of Disposition /Zit la:, Place of Disposition ntOtt., rim+-r
2 (address)
Cl)ILI
0 (section) /t(lot number (grave number)
p Name of Sexton or Person in Charge of Premises GNl' t, _36.
Z (pl ase print)
W //�
Signature Title 0I.�I4fli(
(over)
DOH-1555(02/2004)