Farr, Charles Richard 36
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Charles Richard Farr Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/04/2021 85 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Tupper Lake Village Street Address NYS Route 30,Tupper Lake Village, New York 12986
Manner of Death Pending
Natural Cause Accident ❑Homicide ❑Suicide Undetermined
0 Circumstances Investigation
W Medical Certifier Name Title
CI Russell Rider MD
Address
8561 Newcomb Road,Long Lake Hamlet, New York 12847
Death Certificate Filed District Number Register Number
City,Town or Village Tupper Lake Village 1620 8
ElBurial Date Cemetery,Crematory or Facility Name
04/06/2021 Pine View Crematory
❑Entombment Address
ElCremation Queensbury Town,New York
❑Donation
Is
❑Removal Date Place Removed
and/or and/or Held
H Hold Address
0
a Date Point of
co ❑Transportation
p by Common Shipment
Carrier Destination
El Disinterment
Date Cemetery Address
Date Cemetery Address
❑Reinterment
Permit Issued to Registration Number
Name of Funeral Home Miller Funeral Home 01199
Address
6357 Nys Rte#30, Indian Lake,New York 12842
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
g Address
CC
W
EL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/06/2021 Registrar of Vital Statistics Laurie J Fuller(Electronically Signed)
(signature)
District Number 1620 Place Tupper Lake Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this perm' on:
Z Date of Disposition igl Zi Place of Disposition
LU address/
W
CC (section) (loth'r l e) v_ (grave number)
kt
0 Name of Sexton or Person in Charge of Premiss ��'' n"'t'�
Z ��ji (please prinll .�y�
W ��.Y C tCA�1�`�-'
Signature Title
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) - 014 69
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#