O'Hara, Charles E ,... It 5-I y
N E W YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records ' urial - Transit Permit
Name First Middle Last
Charles E.O'Hara I Sex
Date of Death Male
Age I If Veteran of U.S.Armed Forces,
06/23/2022 81 Years War or Dates
Place of Death Hospital,Institution or
City,Town or Village Harrietstown Town I Street Address Adirondack Medical Center-Saranac Lake Site
21 Manner of Death 0 Natural Cause ❑Accident 0 Homicide OSuicide ❑Undetermined ❑Pending
W
✓ Circumstances Investigation
OW Medical Certifier Name Title
Jessica Shumway PA
Address
2233 State Rte 86 PO Box 471,Harletstown Town,New York 12983
Death Certificate Filed Town Of Karrietstown District Number I Register Number
Cit ,Town or Village 11663 59
Burial Date I Cemetery,Crematory or Facility Name
06/27/2022 Pine View Crematory
Entombment Address
!Cremation Oueensbury Town,New York
Donation
0 Removal Date Place Removed
F and/or and/or Held
fA Hold Address
g❑Transportation Date Point of
G by Common Shipment
Carrier Destination
isinterment Date Cemetery Address
Re interment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,tbury,New Yak 12804
Name of Funeral Firm Making Disposition or to Whom
F. Remains are Shipped,If Otherthan Above
2 Address
Q
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06127/2022 Registrar of Vital Statistics Omuta Kay Spies( r SONO
(signature/
District Number 1663 Place Town Of Harrietstown
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition (917i 122 Place of Disposition ,u,Vim.. 4141-,,,,......
(address)
W
Q (section) ,(lot number) (gra he number)
SName of Sexton or Person in Cha of Premises k 1INDL., ii441
Z please print/
W Signature Title 0 /}('nl�
DOH 1555(07/18)p 1 of 2
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#