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Goff, Charles j , It iti cl/I NEW YORK STATE DEPARTMENT OF HEALTH,Vital Records Section Burial - Transit Permit N• ame First Middle Last Sex Charles A.Goff Male Date of Death Age If Veteran of U.S. Armed Forces, 06/19/2018 91 Years War or Dates 2 Place of Death Hospital, Institution: or • `` City, Town or Village North Greenbush Town Street Address Van Rensselaer Manor Manner of Death© Undetermined Pending Circumstances Investigation i- Medical Certifier Name Title Laura Reutzel NP ; Address 85 Bloomingrove Dr,North Greenbush Town,New York 12180 ' Death Certificate Filed District Number Register Number 4..:- 4,1 City, Town or Village Wynantskill 4156 92 0Burial Date Cemetery or Crematory 06/29/2018 Pine View Crematory ❑Entombment Address m®Cremation Queensbury Town, New York i`i= ) Date Place Removed ❑Removal and/or Held and/or Address Hold Date Point of Transportation Shipment by Common Destination -si3 Carrier Q Disinterment Date Cemetery Address AI Reinterment Date Cemetery Address '! Permit Issued to Registration Number ti N• ame of Funeral Home Jillson Funeral Home Inc 00885 Address 46 Williams Street,Whitehall Village,New York 12887 £T 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. At Date Issued 06/20/2018 Registrar of Vital Statistics ?Cathryn Anne Connolly(Electronically Signed) (signature) # D• istrict Number 4156 Place Wynantskill, New York ViNit I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 7//o/!f Place of Disposition f. ...-/ t-fito , (address) (section) (lot mber) (grave number) . Name of Sexton or Person in Charge of Pr mises /11 L S ^+t^ 'r (please rint) Signature Title / 'mr (over) DOH-1555 (02/2004)