Willard, Charles -46 ;?-Jec
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Charles A. Willard Male
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Date of Death = Age If Veteran of U.S.Armed Forces,
... Aug . 11 , 1991 48 War or Dates No
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Place of Death Hospital, Institution or
:z
i City,Town or Village Lake Placid Street Address Lake Placid Lake
O................................1.�.I.�...�.�...�.......,..................................I.......... ........ ........... ........-.... ...................................................-................ .................................
Manner of Death o Undetermined Pending
Natural Cause E] Accident Ej Homicide Suicide
Circumstances Investigation
.............................. .Name
M ..........am .............................................. ................ .....................................
Medical Certifier e Title
p. H V W Bergamini, M. D .
X-XXX..................................................................................... ........................................................................................... ..... ..............
Address
....... Swiss Road, Lake Placid, N . Y .
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District Number Death Certificate Filed Register Number
City,Town or Village Lake Placid 1560
Date Cemetery or Crematory
11 Burial Aug. 14, 1991 Pine View Crematory
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[3Cremation Address
Quaker Road, Glens Falls , N. Y .
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z Date Place Removed
0 Removal and/or Held
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and/or Hold: ....... .. .. . ........ ..
:: Address
0.........1.1-1---l-1.1-.......... .............................-............... .......- ................... ............. ....................... ........ ..........-
Date Point of
Ln []Transportation by Shipment
0 Common Carrier .......................... ................................... ........................................ ............. ......---..................... .......................
Destination
...................................................... ...........................................................Disinterment ....................................I............. .........................................................................................
Date Cemetery Address
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Date Cemetery Address
Reinterment
El
Permit Issued to Registration Number
Name of Funeral Firm M B Clark, Inc . 00367
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Address
Saranac Ave . , Lake Placid, N. Y . 12946
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44. Name of Funeral Firm Making Disposition or to Whom
:Z. Remains are Shipped, If Other than Above
Address
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Address
4.,
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Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 8/13/91 Registrar of Vital Statistics Cam-
(signature)
60
District Number 15 Place Lake Placid
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z Date of Disposition (T—& Place of Disposition '�6�Fk) r-T1,44il
2 (address)
Uj
Cn (section) (lot number) (grave number)
cc
0
Name of Sexton r Person in Charge of Premises 'F04-j4—XD Aid
fL
z :9 (please print)
LLI Signature n �) A — Title
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DOH-1555 (10/89) p. 1 of 2 VS-61