Charbonneau, Raoul III
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NEW YORK STATE DEPARTMENT OF HEALTH Burial Records Section Burial - Transit Permit
- Name First Middle Last Sex
Raoul �E T Charbonneau Male
tom* Date of Death Age If Veteran of U.S. Armed Forces,
11/28/2011 68 War or Dates No
Place of Death Hospital, Institution or
. 0.4 Town •i 0-,k Lake Luzerne Street Address 179B Hall Hill Rd.
Manner of Death«I Natural Cause C1 Accident ❑Homicide Suicide n Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Aqeel Gillani MD
.< Address Glens Falls,NY
Death Certificate Filed District Number Register Number j}
h.
4 j•#`�owr $i a Lake Luzerne 5656 i `7
Date Cemetery or Crematory
❑Burial 11/28/2011 Pine View Crematory
Address
Cremation Queensbury,NY
Date Place Removed
Z❑Removal I and/or Held
�•.• and/or Address
Hold
Date ( Point of
tl?Q Transportation Shipment
5 by Common I Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to i Registration Number
hri Name of Funeral Home Brewer Funeral Home, Inc. i 00211
t.t: Address
a 24 Church St., Lake Luzerne,NY 12846
,. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
i Permission is hereby granted to dispose of the hums rem ns dese ed ab v as indicated. ,
Date Issued //- ?- // Registrar of Vital Statistics .✓-//L _
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District Number ,�7 S Place .il,,r-�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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2 Date of Disposition ►rov ,0 f lol( Place of Disposition .rPV Crrvv►riat)Uri,
(address)
CA
(section) - (lot number) (grave number)
Name of Sexton or Pers n in Charge of remises �il.AuQl , i h,,,l }
$ (please print) Tr _
411 Signature Title _ CR.e+M�q. lG i
DOH-1555 (10/89) p. 1 of 2 VS-61