Charlebois, Laurette NEW YORK STATE DEPARTMENT OF HEALTH - , ---; Y
Vital Records Section Burial - Transitt Permit
Name First Middle Last Sex
Laurette J. Charlebois Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 13, 2016 80 War or Dates
Me of Death Hospital, Institution or / 1
ri Town or Village G lens ���I1S Street Address tic P,'ies AlU/J/ <: he4 CTr.
Manner of Death E Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined fl Pending
� Circumstances Investigation
Medical Certifier Name ,�^ �� Title / iD
tl eik1SS0.
AddressY e CXe
cksbarc4 /0(/
obi, Certificate Filed g j District Number `p� Register Number
4Town or Village , A —�..c is 1 Cl
ElBurial Date 0 I I )4o Cemetery or_CL 117 Hie I /� - / C.,/eY ,�`
-,F❑Entombment I
VW /u
Address �
.Cremation 2 / 6 tA.Ci jC.� IC.C�1. 0,tutit,s1-4.,2 NI / 7�(roI
Date Place Removed
❑ Removal and/or Held
and/or Address
*-. Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
'
' Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
7 ,, 136 Main Street, South Glens Falls NY 12803
: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 remains described above as indicated.
Date Issued / I)GI I t b Registrar of Vital Statistics I fOc sz,Uk--),
(signs re)
District NumberSbo 1 Place (o Um/.S To, \ \ S .) N t)
.fix, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Y Date of Disposition 1 hi IT Place of Disposition „fgt., ('t+711(14W,,,..
(address)
(section) Sot number) (grave number)
Name of Sexton or Person in Char of Premises ('�r qt., fd��ii
(pi print)
Signature Z-`( .,�;Title / in
(over)
DOH-1555 (02/2004)