Kasal, Charles NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Charles A. Kasai Male
Date of Death Age If Veteran of U.S. Armed Forces,
r May 21,2016 65 War or Dates
Place of Death Hospital, Institution or
• City, Town or Village Hague Street Address 20 Silver Bay Road
tit
°0 Manner of Death Undetermined Pending
X Natural Cause Accident Homicide Suicide
W. Circumstances Investigation
w1 Medical Certifier Name Title
3; Ageel A.Gillani
a Address
102 Park St.,Glens Falls,NY 12801
Death Certificate Filed District Number _ Register Number
City, Town or Village 5-( .
❑Burial Date Cemetery or Crematory
May 24,2016 Pine View Crematory
ElEntombment Address
❑x Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
H Hold
N
O Date Point of
N I !Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
1 Permit Issued to Registration Number
1 Name of Funeral Home Alexander-Baker Funeral Home 00037
I Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
; . Address
l
tom:
._, Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 512'1- \InI tQRegistrar of Vital Statistic t'1 1 n
(signet e)
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 517s-hi, Place of Disposition f4.L.., C onti
2 (address)
W
N
IX (section) �y (lot numb (grave number)
Q Name of Sexton or Person in Charge of Premises GLaAti
tcry
Z (please print)
W Signature 4-1 Title Wen tpk,
(over)
DOH-1555 (02/2004)