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Adams, Charles Collinwood Jr. NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Charles Collinwood Adams Jr. Male Date of Death Age If Veteran of U.S.Armed Forces, 02/10/2022 77 Years War or Dates 1963-1967 �.. Place of Death Hospital,Institution or tZ City,Town or Village Glens Falls Street Address 26 Garfield Street,Glens Falls,New York 12801 O Manner of Death © Natural Cause EtAccident El Homicide El Suicide El Undetermined ❑Pending U Circumstances Investigation W Medical Certifier Name Title G Glen Anderson PA Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 101 ❑Burial Date Cemetery,Crematory or Facility Name 02/14/2022 Pine View Crematory ❑Entombment Address ]Cremation Queensbury Town,New York Donation ❑Removal Date Place Removed and/or and/or Held H N Hold Address 0 LL Date Point of Cl) Li Transportation Q by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Maynard D Baker Funeral Home 01130 Address 11 Lafayette St,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom • Remains are Shipped,If Other than Above • Address W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/14/2022 Registrar of Vital Statistics 9r1egan Moan(ECectronica1 ySigned) (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 211c lZZ Place of Disposition .�a� "lam (address) IILI CC (section) (lot number)s (grave number) O c , C Name of Sexton or Person in Charge of Premises �"�� (plse print) POI it W Signature C Title f! TV DOH-1555(07/18)p 1 of 2 S � ►. 1 644 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#