Woods, Charles dr lb ft?2
NEW YORK STATE DEPARTMENT OF HEALTH Burial - ransit Permit
Vital Records Section
Name First Middle Last Sex
Charles Joseph Woods Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 6, 2012 80 War or Dates Korean
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
lit
im: Manner of Death X Natural Cause Accident j 1 Homicide Suicide Undetermined Pending
BS: Circumstances Investigation
us, Medical Certifier Name Title
P Mary Clarissa Kilayko MD
Address
100 Park Street,Glens Falls,NY 12801
- Death Certificate Filed District Numbe5601 Register Number
City, Town or Village Glens Falls 52
❑Burial Date Cemetery or Crematory
February 10, 2012 Pine View Crematorium
❑Entombment Address
El Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
NI I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
k ' Remains are Shipped, If Other than Above
Address
CR Permission is hereby granted to dispose of the human remains described above as indicated.
w° Date Issued .2` 1 1 Z Registrar of Vital Statistics W
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition Ftb 51 Zia Place of Disposition PNIO,,,,,,) 1!urw.�
Ill
(address)
N
re (section) , ^ (lot nymber) (grave number)
00 Name of Sexton or Pe on in Char of Premises t r(it lit r eN.-t -
W (please print)
Signature Title CrEmA-t
(over)
DOH-1555(02/2004)