Coutant, Chelsea NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Chelsea Donna Marie Coutant Female
Date of Death Age If Veteran of U.S. Armed Forces,
pu 28, 201 7 29 yrs. • War or Dates n/a
Place of Death Hospital, Institution or
Z City, Town or Village Fort Ann Street Address 1 41 1 Patten Mills Rd.
1,11
• Manner of Death❑Natural Cause CiAccident El Homicide ❑Suicide ❑Undetermined 11 Pending
W Circumstances Investigation
W Medical Certifier Name Title
i3 N. Balrsubramaniam MD.
Address
50 Broad St. , Waterford, NY.
Death Certificate Filed District Number Register Number
City, Town or Village Fort Ann 5754
•
Burial Date Cemetery or Crematory
Aug. 29, 2017 PineView Crematorium
['Entombment Address
®Cremation Quaker Rd. , Queensbury, NY. .
Date Place Removed
Z El Removal and/or Held
r and/or Address
r." Hold
0 Date Point of
❑Transportation Shipment
Q by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Mason Funeral Home 011 Registration Number
Name of Funeral Home
Address
18 George St. , Fort Ann, NY. 12827
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
it
LEI
it
Permission is hereby granted to dispose of the human remai described abov as' dicated.
Date Issued 08/29/201 7 Registrar of Vital Statistics
(signature)
District Number 5 7 5 4 Place ¢71-. �j2
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI• Date of Disposition_clialn Place of Disposition aiIL- �r++,c fori.,...
(address)
W
CC (section) // (lot numb j (grave number)
Cv Name of Sexton or Person in Char a of Premises ti.. .it.4iIt
"Z 0 ( lease print)
ILI
Signature yt Title /R011j
(over)
DOH-1555 (02/2004)