Tall III, Charles NEW YORK STATE DEPARTMENT OF HEALTH �0 0
Vital Records Section Burial - Transit Permit
::f. Name First Middle Last Sex
I'" Charles H. Tall,III Male
r*'f Date of Death Age If Veteran of U.S. Armed Forces, 0 I_ 7 I
1 March 16, 2015 83 War or Dates
1 Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 1
Medical CertifierX Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
0
' Medical Name Title
Jennifer L.Donovan to
:Kr
Address
'•s 100 Park St,Glens Falls,NY 12801
4•:•: Death Certificate Filed District Number Register Number.
'r" City, Town or Village Glens Falls 5601 fi �3
r. Y 9
❑Burial Date Cemetery or Crematory
March 18, 2015 Pine View Crematorium
❑Entombment Address
iJ Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z I 'Removal and/or Held
and/or Address
r.' Hold
N
Q Date Point of
O. Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
,.';�.
Permit Issued to Registration Number
E Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
•: Address
€f'1:: 407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
::1:* Permission is hereby granted to dispose of the human remains described above ap indicated.
Date Issued 3 1/ 7 /15. Registrar of Vital Statistics LCA' -110'‘12.- U&•)
(signature,
':; ; District Number 5601 Place
:r Glens Falls) /V 4%
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 3- 1 ci-is Place of Disposition T ►ne v .e,,�; Cr.evnc ;y'll„,,
W (addfess)
co
O (section) (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises 1 i vy%ttkii 'co AehQ
W g 4A„ /�/ C` (please print)
Signature4G L,,_ (/�/1/L Title e„,u,k.c,�, t�55�
(over)
DOH-1555(02/2004)