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Leathers, Charles NEW YORK STATE DEPARTMENT OF HEALTH BUrIaI - Transit Permit Vital Records Section Name First Middle Last Sex Charles Leathers male ..:: :..... . ..... ......................:.......:.:........................ Date of Death Ag,.e... If Veteran of U.S.Armed Forces, August 20, 1990 54 War or Dates no .. ....:.............:.:::..:..:......:...:.:....... . . ... ............:..::.:::............................... Place of Death Hospital, Institution or City Town or Village City of Glens FallsStreet Address Glens Falls Hospital ...................................................:.:......:.....::...................................................... .. ................ W Manner of Death ❑X Natural Cause Accident ❑Homicide ❑ Suicideo Undetermined Pending Circumstances Investigation { ...... ..................................................: :.. ........ ............ .. :::.: ... _ .............. Medical Certifier Name Title © S. Richard Spitzer..: MD ...............: .......... ..........I..........::.:::::........ Address Box 139, Glens Falls, New York 12801 ..... ..... _ ......... ........... .._...._. _.... _....__ .. ......_ .._._. _. __. ...._ ..... ................................................................................................................................................................................................................................................................................... Death Certificate Filed District Number Register Number City,Town or Village City of Glens Falls 50 G I � Date Cemetery or Crematory ❑Burial . . August .27., 1990 Pine View Crematory ®Cremation : Address Town of Queensbury, New York Z Date Place Removed OI', ❑ Removal and/or Held F-'' and/or Hold .................... .. ...... ....... . ....... . ....... .: ............ Address 0...::::.....:. : . _ .......................................................................... ..... ... a' Date Point of to ❑Transportation by p Shipment Common Carrier _ .......... ........................................................... Destination .::.....: _ ...:: ...... ❑ Disinterment Date Cemetery Address ..... ....::........ .......... _ .... .::::... El Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Firm Regan and Denny Funeral Service, Inc. 01634 . ...... ... .::...... . ..... . ..::::. ............. _ ........:.... .. Address 26 Quaker Road, Queensbury, New York 12804 ::::.... ................................::.. ...... ............... #- 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 hum remains describ%id above as indicated. Date Issued Registrar of Vital Statistics (signature) District Number Place �t,n d�C(� (✓11 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition Place of Disposition 2',I (address) w N (section) (lot number) j (grave number) pName of Sexton r Person ' Charge of Pr ises ,�lc��// ��/ /� Z _ (please print) �-- w Signature Title DOH-1555 (10/89) p. 1 of 2 VS-61