Fuller, Charles Wilfred Jr. CF
NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Charles Wilfred Fuller Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/27/2024 77 Years War or Dates
i_ Place of Death Hospital,Institution or
Z City,Town or Village Johnsburg Town Street Address Elderwood at North Creek
W
`p Manner of Death n NaturalCause nAccident nHomicide nSuicide ❑Undetermined ❑Pending
UICircumstances Investigation
W Medical Certifier Name Title
Jennifer Donovan DO
Address
112 Ski Bowl Rd,Johnsburg Town,New York 12853
Death Certificate Filed NYS State Registration Office District Number - Register Number
City,Town or Village 8888
Burial � Date Cemetery,Crematory or Facility Name _
03/01/2024 Pine View Crematory
nEntombment Address
FK—Cremation Queensbury Town,New York
Donation
ZZ Removal L_IDate Place Removed
and/or and/or Held
H Hold Address
(n
0
a Date Point of
N nTransportation
p by Common Shipment
Carrier Destination
nDisinterment
Date Cemetery Address
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
F_ Remains are Shipped,If Other than Above
5 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/01/2024 Registrar of Vital Statistics E'.a6ethi 7 llanriiCuo/mligs(6lctronuad:yi ,ner)
(signature)
District Number 8888 Place NYS State Registration Office
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 3-,7 Ql?. Place of Disposition ,%)e e 're-m•t-4
2 (address)
W
CC (section) '(lot nu ber) (grave number)
aName of Sexton or Person in Charge of Pr ises IL<=yir)ad at('
(please print)
lL Signature / Title G
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b)
IReceipt
Human remains of delivered on , 20
f`
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#