Webster, Charles NEW YORK STATE DEPARTMENT OF HEALTH , +.1 4N7
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Charles Omar Webster Male
Date of Death Age If Veteran of U.S. Armed Forces,
P February 2, 2014 79 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
Investigation
al
la Medical Certifier Name Title
Ageel Gillanni,
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number 0' Register NuumOber
City, Town or Village
0 Burial Date Cemetery or Crematory
February 11, 2014 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
and/or Removal and/or Held
Hold Address
_ Date Point of
01.{ā¯‘Transportation Shipment
A. by Common Destination
Carrier
7 0 Disinterment Date Cemetery Address
0 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
V Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
. Address
Permission is hereby granted to dispose of the human remains described above as indicated.
4 Date Issued h I t / / / Registrar of Vital Statistics W Cam., U4J
f (signature)
R District Number 3 60/ Place 6 S o I ) S !'v y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
ul Date of Disposition 02/11/2014 Place of Disposition Quaker Road Queensbury,NY 12804
a (address)
iir
Wes,, (section) d(Ibt number) (grave number)
,Name of Sexton or Person i harge of remises G L( SnM
(pf ase print)
,,LP,-, Signature IL Title C(7 0119-idi7
(over)
DOH-1555 (02/2004)