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Simmons, Charles Norman 5$ NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Charles Norman Simmons Male Date of Death Age If Veteran of U.S.Armed Forces, 01/17/2022 86 Years War or Dates 1954-1958 Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital pManner of Death ©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending t.J C.) Circumstances Investigation W Medical Certifier Name Title Christopher Smith MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 45 ❑Burial Date Cemetery,Crematory or Facility Name 01/19/2022 Pine View Crematory ❑Entombment Address ElCremation Queensbury Town,New York ❑Donation ZO ❑Removal Date Place Removed and/or and/or Held _ N Hold Address 0 O. Date Point of to Li Transportation 5 by Common Shipment Carrier Destination El Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above 'g Address CIC • Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/19/2022 Registrar of Vital Statistics !Megan Noiin(ECectronica1TySigned) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition i/riIZZ Place of Disposition (address) W CC N (section) (lot number/ {� (grave number) (,!£�1,-- Name of Sexton or Person in Charge o misesJ /3 lease print Nnl tI !✓U Signature !� Title `efM�n DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt • Human remains of a' ' delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# t� SIMMONS 1LF NAME Charles Simmons Lot Owner: Family Plot Lot# Family Plot Grave# Case: Urn Died: 1 /1 7/22 Interred: 8/5/22 Funeral Home: M.B Kilmer Fh Cemetery: Friends Cemetery