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Chardwick, Merton NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Merton 0. Chadwick male r<' Date of Death Age If Veteran of U.S. Armed Forces, 06/14/2006 84 War or Dates WWII 14 Place of Death Hospital, Institution or City, xc� Glens Falls Street Address Eden Park HC Center Manner of Death®Natural Cause Ei Accident Ei Homicide Ei Suicide 0 Undetermined ❑Pending tli L. Circumstances Investigation at Medical Certifier Name _. Title Jennifet Stratton, MI) Address 14 Manor Dr. , Queensbury, NY 12804 Death Certificate Filed District Number Register Number »' City,)11XXAXIMEREUX Glens Falls 5601 Z g 3 ©Burial Date Cemetery or Crematory 06/19/2006 Pine View Cemetery El Entombment Address iNii OCremation Queensbury, NY 12804 Date Place Removed g�Removal and/or Held r=" and/Holdor Address U Date Point of 0 Li Transportation Shipment G1 by Common Destination Carrier El Disinterment Date Cemetery Address niiQ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan & Denny Funeral Home 01519 Address 53 Quaker Road, Queensbury, NY 12804 Name of Funeral Firm Making Disposition or to Whom F_-? Remains are Shipped, If Other than Above Address It ui cL Permission is hereby granted to dispose of the human remains described above as indicated. .:::;1;i Date Issued 'I51 ri 10 1) Registrar of Vital Statistics 'go A-C2.4.. 1 w (signature) • District Number 5 / j Place .6 Isziv,S Avs p k I I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: k ILI Date of Disposition 6/19/06 Place of Disposition PINE VIEW CEMETERY,QUEENSBURY NY (address) C f UNADILLA EXT. 30-D 3 C (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises MICHAEL GENIER 2 (please print) iiil SignaturAVAASLA 9JIMAAN• Title SUPT. (over) DOH-1555 (02/2004)