Fudger, Charles NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Charles H. Fudger Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/16/2015 68 years War or Dates
f4 Place of Death Hospital, Institution or
down or\AIM illGreenfield Street Address g1 Alpine Meadows Road
Manner of Death aNatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
ili Circumstances Investigation
la Medical Certifier Name Title
0 Dr Gillani Attending Physician
Address •
102 Park St., Glens Falls New York 12801
Death Certificate Filed District Number Register Number
Cown or X Greenfield 4557 17
❑Burial Date Cemetery or Crematory
❑Entombment 10/17/2015 i Pineview
Address
aCremation Queensbury, N Y
Date Place Removed •
1 ❑Removal and/or Held
and/or Address
I= Hold
0.
0 Date Point of
CL 0 ta. Transportation Shipment
G by Common Destination
Carrier
El Disinterment Date Cemetery Address
iig! ❑Reinterment Date Cemetery Address
iiR;;> Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
Address
7 Sherman Avenue,Corinth, New York 12822
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
a Address
fr
ill 7
Permission is hereby granted to dispose of the human re airs descr.Pil
above as/ dicated.
Date Issued 10/17/2015 Registrar of Vital Statistics •
•• ' F 1.1
(signature)
sE District Number 4557 Place Greenfield
.::::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition ,OJJr l/,6 Place of Disposition �w. (. *,�
' (address)
111
ill
IX. (section) / s(lot nummaer) (grave number)
CI Name of Sexton or Person in Ch rge of Premises 6,i T '1`"'"r't/
ease print)
114 Al
Signature Title OMR
(over)
DOH-1555 (02/2004)