Charbonneau, Robert E NEW YORK STATE DEPARTMENT OF HEALTH • 13 L
Vital Records Section L Burial - Transit Permit
Name First Middle Last Sex
Robert Earl Charbonneau Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 10, 2015 60 War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death X❑ Natural Cause EiAccident 0 Homicide 0 Suicide riUndetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
O Jennifer Donovan, D.O.
Address
Death Certificate Filed District Number Registn� mber
City, Town or Village 5601 as
❑Burial Date Cemetery or Crematory
January 14, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ri Removal and/or Held
• and/or Address
H Hold
N Date Point of
d ❑Transportation Shipment
UN by Common Destination
a Carrier
ElDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
w
a' Permission is hereby granted to dispose of the human remains describ b 77 i - ed.
Date Issued 04212.043—Registrar of Vital Statistics G'C
(signature)
District Number 5601 Place )7t.:)0 /X ,Uy
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 01/14/2015 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
W
CO (section) (lot number) (grave number)
pName of Sexton or Pers n in Charge of Premises +r,ste0L- SewAr
(please print)
al Signature ��-- Title elZ(M tT66L
(over)
DOH-1555 (02/2004)