Adams, Charles "NEW YORK STATE DEPARTMENT OFHEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Charles S.. Adams _.....
.. ......:................... ................................... ..
...... .. male........
If Date of Death Age
If Veteran of U.S.Armed Forces,
January 11 1994 87 War or Dates
!— _..........Y..:..: .......... ..:.............:. ........ ......... ........... .no. ...... ......... ....................................................
Z: Place of Death Hospital, Institution or
10
City,Town or Village City of Glens Falls Street Address Glens Falls Hospital...
G. Manner of Death
....._ ........
W Natural Cause Accident Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
...... . ... .......................................................... .: _ ......... ...: :.-... ......... ........
f Medical Certifier e Title
0; M. J. Crook
............................ MD
Address
62 Elm Street. Glens Falls. York 12801
_.............
Death Certificate Filed District Number / Register Number
City,Town or Village City of Glens Falls 6f
Date Cemetery or Crematory
❑Burial -January 14 1994 Pine View Cremator
..........:......... Y.....:.:...r... y __ .:.
E3 Cremation
Address
Queensbury, New York
.:. .. .... . ............
Z Date Place Removed
0; ❑ Removal and/or Held
Hand/or Hold ..................:. ...... ...... .........: _ . ..... ::.-.
Address
CL Date Point of
o ❑Transportation by: Shipment
pi 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. 01583.
... . . ....
Address 26 Quaker Road, Queensbury, New York 12804
. ............................................. .:. :..:....
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
................................................ ....: ................:.. ........ . ... ........
.. ............................ .:..
ru>
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued /!�{=- Registrar of Vital Statisticsr
(signature)
District Number .� Place `
I certify that the remains of the decedent identified above ere disposed of; ccordance with this permit on;
Date of Disposition Place of Disposition % /Y� ///,��,/ C/f�jr�/�/6 f /( x
g (address)
W''.
(section) (lot number) (grave number)
p Name of Sexto or Person i Charge of Premises
Z -�-
u1 Signature (please print) Title
DOH-1555 (10/89) p. 1 of 2 VS-61