Jordon, Charles NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
la
Charles Jordon Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 26, 2015 82 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Westmount Health Facility
Manner of Death FriNatural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined IT❑ Pending
Circumstances Investigation
Medical Certifier Name Title
re Roslyn Socolof, M.D. Dr.
Address
100 Broad Street Glens Falls, NY��1�,�28-01
et Death Certificate Filed Dist J`a_,� er Regist.�r umber
City, Town or Village Queensbury
of
❑Burial Date Cemetery or Crematory
May 28, 2015 Pine View Crematory
W.I=1 Entombment Address
Cremation
;® Quaker Road Queensbury,NY 12804
itia Date Place Removed
❑ Removal
and/or and/or Held
Address
Hold
Date Point of
`;❑Transportation Shipment
`" by Common Destination
. Carrier
tit
itt-iw ❑ Disinterment
Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
"$ Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
is 82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
- Permission is he eby granted to dispose of the human C...,m n "descri•i . . -o - a al dicated.
r
'9. Date Issued 1 Registrar of Vital Statistics ; ((2 ,,,,io
(signature)
District Number , 1 Place ` (L,tO\A. Cbli
itiw
"' I certify that the remains of the decedent identified abov ere disposed of in acc nce with this permit on:
t Date of Disposition 05/28/2015 Place of Disposition uaker Road Queensbury,NY 12804
(address)
• s (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
t is , 5
,- 1____
(p ase print)
Signature Title frAotiftu,
(over)
DOH-1555 (02/2004)