Adams, Charles NEW YORK STATE DEPARTMENT OF HEALTH ' •Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Charles A. Adams Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 21,2012 82 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Kingsbury Street Address 25 Helen Street
pManner of Death X Natural Cause l i Accident pi Homicide Suicide l i Undetermined n Pending
IAJCircumstances Investigation
w Medical Certifier Name Title
C Christopher Hoy,MD
Address
102 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Kingsbury
❑Burial Date Cemetery or Crematory
❑Entombment June 25, 2012 Pine View Crematorium
Address
®Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I Removal and/or Held
and/or Address
N Hold
O Date Point of
n Transportation Shipment
p by Common Destination
Carrier
ri Disinterment Date Cemetery Address
ri 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
Ir
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 4-4S /?—Registrar of Vital Statistics jia.P
l� (signature)
District Number 5-7 L d— Place Kingsbury
I certify that the remains of the decedent identified above were disposed of in accordance�� with this permit on:
W Date of Disposition lot f Z Place of Disposition i,�t<sj (.rt ator
(address)
W
(section) (lot number)c (grave number)
QName of Sexton or Person in Charge of emises 4Ilit114r SGh�n
Z (please print)
Title (,t( 10.4 a d(..
Signature
(over)
DOH-1555(02/2004)