Purchla, Charles 4
NEW YORK STATE DEPARTMENT OF HEALTH 4
Vital Records Section Burial - Transit Permit
` Name First Middle Last Sex
Charles Purchla Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 30, 2014 70 War or Dates
H Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death In Natural Cause ❑Accident n Homicide n Suicide n Undetermined n Pending
Circumstances Investigation
W Medical Certifier Name Title
Ct Jennifer L.Donovan
Address
100 Park St,Glens Falls,NY 12801
Death Certificate Filed District Number Register N mber
City, Town or Village Glens Falls 5601 5
❑Burial Date Cemetery or Crematory
February 3,2014 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z [ I Removal and/or Held
and/or Address
1.7-- Hold
U)
O Date Point of
N ['Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Ti Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
CZ
d Permission is hereby granted to dispose of the human remains descri ed abov s i ted.
Date Issued Q-0/206J4 Registrar of Vital Statistics
(signature)
District Number 5601 Place Glens Falls `,t/V 1 -bo/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition a/4111 Place of Disposition ine Vito t or,ti.
2 (address)
W
U)
0' (section) / (lot number)c (grave number)
QName of Sexton or Person 'n Charge o- Premises d As r kJQ�,�,40-
Z ( ease print)
W
Signature Title
(over)
DOH-1555(02/2004)