Charron, Estelle It ` ji700
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Estelle L. Charron Female
Ai Date of Death Age If Veteran of U.S. Armed Forces,
Sept. 26,2016 84 War or Dates
Place of Death Hospital, Institution or
ICity, Town or Village Glens Falls Street Address 12 Katherine St.
Manner of Death I XI Natural Cause ElAccident El Homicide E Suicide n Undetermined n Pending
Circumstances Investigation
` Medical Certifier Name Title
.,;: Robert Love MD
Address
3 Irongate Center,Glens Falls,NY 12801
Death Certificate Filed District Number 5LL�1 �tegis�N,u�ml�er
City, Town or Village Glens Falls ti �.. l_)
❑Burial Date Cemetery or Crematory
Sept. 27, 2016 Pine View Crematory
❑Entombment Address
❑x Cremation Queensbury, NY
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
NElTransportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
"r> Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
+''407 Bay Rd. Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
IAddress
1
, ` Permission is hereby ranted to dispose of the human re ains d cribed a ve as in,icate..
Date Issued Q� �� �p/(� Registrar of Vital Statistics ,� ._ / e
(signs ure)
District Number 5loo/ Place `, ,_ ;D / a jL
I certify that the remains of the decedent identified above were disposed of in accordant with this permit on:
W Date of Disposition °1 f Za jll, Place of Disposition gat,,,/ C url.
W (address)
co
cc (section) P// (lot number (grave number)
QName of Sexton or Person in Charge of Premises 141i4t \t i4410
wZ ( lease pri
Signature a Title
(over)
DOH-1555(02/2004)