Cole, Charles NEW YORK STATE DEPARTMENT OF HEALTI4 4. I
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Charles Donovan Cole Male
Date of Death Age If Veteran of U.S. Armed Forces,
nn/0R/7n1 3 83 years War or Dates
}- Place of Death Hospital, Institution or
Z to City, Tows illaRge
XX dens Falls Street Address Glens Falls Hosp
WManner of Death❑(Natural Cause Accident ❑Homicide Suicide ❑Undetermined 0 Pending
Circumstances Investigation
ut Medical Certifier Name Title
0 Noelle Stevens M D
Address
100 Broad Street Glens Falls, N Y 12801
ti',1 Death Certificate Filed District Number Register Number
iliiii City, TowTheiieilipotofC;Ienc Falls 5Bn1 96
❑Burial Date Cemetery or Crematory
❑Entombment 03/n8/2013 Pine View Crematorium
iiN Address
gg❑CCemation Oueensbury, NY 12804 •
Date . Place Removed
.❑Removal and/or Held
VP and/or Address
Iol
— Hold
0 Date Point of
IL Transportation❑ p Shipment
Gs by Common Destination
Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan Funeral Home 01821
Address
11 Aiqonkin Street Ticonderoga, N Y j a V't3
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
t
ILI
Permission is hereby granted to dispose of the human remains described above as indicated.
iiiiAt
NO Date Issued 03/07/2013 Registrar of Vital Statistics U\,v`A -N_���.t„�j
��D p (signature)
District Number Place
5601 glens Falls IV V
Iii I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 3—S-5 Place of Disposition �„� a rei%cfrt,,`
III (address)
IA
CC (section) A Plot number) (grave number)
0 Name of Sexton or Perso in Charge f Premises nt=1 B�k�
(p ase print)
la Signature Title Gl% u'gr0.,
(over)
DOH-1555 (02/2004)