Smith, Charles NEW YOM STATE DEPARI-ME:N1- OF I-IEALTH
vital
."MR1�d1Secliom Burial - Transit Permit
-77
Name First I;lid�.11e Last Sex
Charles Smith male
Dale of Death Aye If Veteran of U.SAm,ed Forces,
12/09 j 1998_ _ I _— 81 - War or Dates- — Army Air Corp.
Place of Death Hospital. Insifiuliot) or
(CRY, Town_oXAMX)M- Queensbury —_ — Streel Address Westmount Health Facility
Manner of Death Nalui al Cause [�Accident []Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Cei lilier Name Title
Bernardo Villa-i an, MD
Address
90 South Street Glens Falls NY 12801
Death Cer,lilicale Filed District Number Register umber
< , Town (AXANW Queensbury 5657 l
Date Cemetery or Cteinalory
❑Burial 12/10/1998 Pine View Crematory
Address _
MCremalion Quaker Road, Queensbury, NY 12804
F ------`-- -Dale -- --- -— -- Place Removed
Removal - -. -- - and/or Held
V and/or Address
Hold
p Date Poirl of
F]Tiansportation _ _ Shipment
j5 by Conmion Destination
Carr i,3r
0 Disimterrmenl Date Cemetery Address "
Reinlennent Date Cemetery Address
Permit Issued to Registration Nur,ber
(Jame ot_Fu_neial I-I_uime Singleton-Healy Funeral Home 01773
Address _ 407 Bay Road, Queensbury, NY 12804
Ncime of Fuiieral Firm Making Disposition or to Whom
Remains are Stripped, If Other than Above
... Addi ess
Permission is hereby granted to dispose of the human rerna.(,is desciipec--a it icated.
Date Issued j - -q Registrar of Vital Statistics r
I (sign le)
22
District Number �jl>,5 Plac -
ceilify that flip ►eniaitis of the decedent ideirlified above e disposed of it accord ,ce h this pernil or:
t l a r
z Date of Disposiliol��1 lace of Disposition
W (address)
t
rx (section) (lot ill b r)T-- ,(yyave number)
Name of Sexton or Person i r Change of Premises
7 please print) �n
III Sig Title
DOFI-1555 (10/89) p. 1 of 2 VS-61