Jones, Charles NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Charles M. Jones Male
Date of Death Age If Veteran of U,S. Armed Forces,
September 20,2013 83 War or Dates
1.., Place of Death Hospital, Institution or
iZ City, Town or Village Bolton Street Address 49 Coolidge Hill Road
p Manner of Death X Natural Cause Accident Homicide Suicide I Undetermined Pending
0Circumstances Investigation
uj 0 Medical Certifier Name Title
Bryan Smead
Address
Bolton Health Center,Bolton Landing,NY 12814
Death Certificate Filed Bolton District Number Register Number
City, Town or Village 5650 13
El Burial Date Cemetery or Crematory
Entombment September 23,2013 Pine View Crematory
Address
0 Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Zz I I Removal and/or Held
and/or Address
E Hold
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0 Date I Point of
can" I I Transportation I Shipment
p by Common Destination
Carrier
I
Disinterment Date Cemetery Address
Date Cemetery Address
I I Renterment I n'
Permit Issued to I Registration Number
Name of Funeral Home Alexander-Baker Funeral Home I_ 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped, If Other than Above
2 Address
III
a
Permission is hereby granted to dispose of the human remains descri•ed ove as i dicated.
Date Issued 9-23` 13 Registrar of Vital Statistics 0-'
'
(signature)
District Number 5650 Place Bolton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Date of Disposition `�)/5113 Place of Disposition u►v arw�-
(address)
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(section)CZ
(t t numbs Q A -3 (grave number)
ZName of Sexton or Person in Charge of Premises p,S , r J{i�t}
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Signature L. Title jR a(l
(over)
DOH-1555 (02/2004)