Spellman Jr., Charles Carl LF It- Li g Li
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NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Charles Carl Spellman Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
06/09/2023 71 Years War or Dates 1970-1974
i_ Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address Glens Falls Center for Rehabilitation and Nursing
IJJ
W n Manner of Death Natural Cause Accident I I Homicide Suicide Undetermined ❑Pending
U I I Circumstances Investigation
W Medical Certifier Name Title
CI Elizabeth Bessette NP
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 87
Burial Date Cemetery,Crematory or Facility Name
E.
06/12/2023 Pine View Crematory
Entombment Address
[]Cremation Queensbury Town,New York
EIDonation
0❑Removal Date Place Removed
and/or and/or Held
I Hold Address
N
0
d Date Point of
(/) Transportation
p by Common Shipment
Carrier Destination
[]Disinterment
Date Cemetery Address
11 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
p-. Remains are Shipped,If Other than Above
l Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/09/2023 Registrar of Vital Statistics Carolinexkkgard?Bar6er4'kt-ironic-a!lySigneta
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I— q
Z Date of Disposition 4 113 IZ3 Place of Disposition AL .----.
2 (address
W
Cr (section) (lot number) (grave number)
gName of Sexton or Person in Charge of ises . ssi (r
Z lease print) /'
L Signature Title [ mq��
..;2
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 7r
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#