Birkhan, Charles NEW YORK STATE DEPARTMENT OF HEALTH i s (1
Vital Records Section Burial - Transit Permit
Name Firstharles Middle A L�stkhan Sex Male
Dateof Death
1 A 85years If Veteran of U.S. Arrm4ed Forces,�
War or Dates
.1 Place of Death Hospital, Institution or
Glenville
down or MAW( Glenville Address Glendale Home
ILI
Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide El Undetermined 0 Pending 1
W. Circumstances Investigation
tu Medical Certifier Name Title
Jung Wen Chen M D
Ad�r, s River Road, Niskayuna, N Y 12309
Death Certificate Filed District Number Register Number
6 , f'own or igfax Glenville 4651 88
❑Burial Date Cemetery or Crematory
08/19/2011 Pine View Crematorium
❑Entombment Address
["Cremation Queensbury, N Y
Date Place Removed
Z Removal and/or Held
9,❑and/or Address
t Hold
4
0 Date Point of
tffi Q Transportation Shipment
C by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Brewer Funeral Home, Inc. Registration0 Number
Name of Funeral Home
li Address
z4 Church St. Po Box 500, Lake Luzerne, Ny 12846
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Address
IX
CL
Permission is hereby granted to dispose of the human remains s ibed above as i icated.
Date Issued 08/19/2011 Registrar of Vital Statistics i /t>
(signs u )
District Number 4651 Place Glenville
1...,-.; certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�
Date of Disposition -t2"t( Place of Disposition �,�u,,w `ffr r torw`..
(address)
ill
CA
CC (section) A (lot numbed}. (grave number)
CI• Name of Sexton or Pers n in Charge f Premises ` 1,t.s.t J +r . .i,.s
Z C (please print)
• Signature • IL Title t-PgritV01.1
(over)
DOH-1555 (02/2004)