Kloss, Charles NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
• Name First Middle Last Sex
• Charles William Kloss Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/27/2018 73 Years War or Dates 1962-1965
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Wesley Health Care Center Inc
Manner of Death au=Natural Cause EI Accident 1=IHomicide El Suicide El Undetermined ri Pending
Circumstances Investigation
• Medical Certifier Name Title
Eric Santell NP
o
fit Address
131 Lawrence St,Saratoga Springs,New York 12866
-6 Death Certificate Filed District Number Register Number
• City, Town or Village Saratoga Springs 4501 419
❑Burial
Date Cemetery or Crematory
07/27/2018 Pineview Crematorium
['Entombment Address
®Cremation Queensbury Town, New York
Zfti
ev Date Place Removed
❑Removal and/or Held
i, r and/or Address
Hold
Date Point of
Q• Transportation Shipment
by Common Destination
Carrier
El Disinterment Date Cemetery Address
Date Cemetery Address
• Q Reinterment
pg Permit Issued to Registration Number
• Name of Funeral Home Densmore Funeral Home Inc 00448
• Address
7 Sherman Ave,Corinth,New York 12822
, Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
{ Address
• Permission is hereby granted to dispose of the human remains described above as indicated.
h
Date Issued 07/27/2018 Registrar of Vital Statistics John rn Franck &ectronicaltySigned)
'',
(signature)
h�' District Number 4501 Place Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
r Date of Disposition` a,itc Place of Disposition ,,pin% L,R
< G &n4 oCY
w,zt
(address)
(section) (lot number) (grave number)
r Name of Sexton or Person in Charge of Premises 4 et v"- 1)' Se 4:4- ,
(plea se print)
.` Signature Title Grt/l7ei cir
(over)
DOH-1555(02/2004)