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Gordon, Charles NEW YORK STATE DEPARTMENT OF HEALTH I IA0 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Charles Edward Gordon Male 4`t E Date of Death Age If Veteran of U.S.Armed Forces, , January 9, 2018 82 War or Dates k Place of Death Hospital, Institution or City, Town or Village Fort Edward Street Address 23 Thomas Ave Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation s Medical Certifier Name Title Sh Ageel Gillanni, Address , 102 Park Street Glens Falls, NY 12801 '-' '' Death Certificate Filed District Number Register Number City, Town or Village 5'155 1 ❑Burial Date Cemetery or Crematory w : January 10, 2018 Pine View Crematorium ❑Entombment I- Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed .,El Removal and/or Held and/or Address ,° Hold St. Mary's Cemetery Date Point of .,❑Transportation Shipment (/) by Common Destination Carrier Nok ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number ,,_ Name of Funeral Home Carleton Funeral Home, Inc. 00281 ,', ,. Address ,,', 1 -* Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is ereby granted to dispose of the human re 'ns described a ove s indicated. q Date Issued $ Registrar of Vital Statistics s hI± iTcL�(signatu ) .l District Number 55 Place �(��(}� ;,1,,,,,,, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 7.,n/V,Z4.4/ 6.te-feted Date of Disposition 01/11, 2018 Place of Disposition Quaker Road Queensbury,N 12804 (address) ti (section) (lot umber) (grave number) 0F Name of Sexton or P rs i arge of Premises ��-<< G-vr �,.mot z (please print Signature Title C--''-e_ (over) DOH-1555 (02/2004)