Eisenberg, Charles NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
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Name First Middle Last Sex
Charles William Eisenberg Male
Date of Death Age If Veteran of U.S. Armed Forces,
0712812 12 57 years War or Dates
F- PP1 re o ea Hospital, Institution or
litZ Cit ow d -.- Street Address
it-w �• XX Glens F ParkbCdFatFainsintidY
1 1bFanner of'D"e h NaturalCauset Accident Homicide Suicide Pending
W ./ Circumstances Investigation
ta Medical Certifier Name Title
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Addraseph C Mihinda M D
20 Murray Street Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
Towse%
' unaI cie�XX Clcns Falls Cemetery or Crematory 359
['Entombment Address07/30/2012 Pine View Cemetery
Cremation •
Queensbury, NY 12804
Date Place Removed
❑Removal11119 and/or Held
and/or Address
I= Hold
to
0 Date Point of
5 D Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date . Cemetery Address
El Renterment Date Cemetery Address
iM Permit Issued to Registration Number
Name of Funeral Home Wilcox 8 Regan Funeral HomP 01821
Address
11 Algonkin Street Ticonderoga, N Y l 13
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;' Address
L
"` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/30/2017 Registrar of Vital Statistics A) Cj.1 V .
(sins
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s District Number Place / `a��
5601 Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
ILI Date of Disposition 7131111. Place of Disposition a4Ut4s, Cw{,rt•.
(address)
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1Z (section) // _ (lot numh) (grave number)
O. Name of Sexton or Person in Charge f Premises h���} J`+4
11-
2 I (please print)
14 Si nature AI Title Cite- rTOYt
(over)
DOH-1555 (02/2004)