Naylor, Charles Gordon Jr. (L.0 it 3:),3
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Charles Gordon Naylor Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/01/2022 35 Years War or Dates
i_ Place of Death Hospital,Institution or
Z City,Town or Village Hudson Falls Village Street Address 121 Main Street Apt.#7,Hudson Falls Village,New York 12828
W Manner of Death Undetermined Pending
O El ❑Accident �Hornicide ❑Suicide
W
V Circumstances Investigation
W Medical Certifier Name Title
C Robert Lemieux Coroner
Address
415 Lower Main Street,Hudson Falls Village,New York 12839
Death Certificate Filed Village of Hudson Fans District Number Register Number
City,Town or Village 5726 22
Burial Date Cemetery,Crematory or Facility Name
04/08/2022 Pine View Crematory
Entombment- Address
▪Cremation Queensbury Town,New York
▪Donation
D0Removal Date Place Removed
and/or and/or Held
NHold Address
0
a Date Point of
U) Transportation Shipment
a by Common
Carrier Destination
Date Cemetery Address
❑Disinterment
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
F Remains are Shipped,If Other than Above
2 Address
Q
w
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04104/2022 Registrar of Vital Statistics cymtlia y Barran A4ectmrtica!!y'Signed)
(signature)
District Number 5726 Place Village Of Hudson Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
CI
W y u�
Date of Disposition ��+2t Place of Disposition , L �""
2 (address)
W
In
CC (section) A _ (lot number) (grave number)
Q
SName of Sexton or Person in Charge of Premises iv i-- Miu It
Z L n �� ease print)
W Signature ./��y// Title IC,
O IfilA C
DOH 1555(07/18)p 1 of 2
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Public Health Law Sec. 4145(2b)
1 Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# I