Chmillewski, Chester i NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
illiii Name First Middl Las Sex ®
Date of Death If Veteran of U.S. Armed Forces,
/fie , 46,6, War or Dates .
140 Place of Death Hospital, Institutio
City, Town or Village � Street Address <� ��
Manner of Death atural Cause ❑Accident Li Homicide 0 Suicide EI UndeterminedPending
Circumstances Investigation_
Medical Certifier Name Title
Add ess > ` Z4
Death Certificate Filed ���^^ District Number Register Number
III City, Town or Village, . ,f , ..S'?oO
I Date Cemeter or Crematory
L_J 3urial in?//`f �• (/. A�,-�-
Address
El Cremation 'l r
Date P ce Removed
fl❑Removal and/or Held
�-- and/or Address
Hold
4 ' Date Point of -
NQ Transportation Shipment
fl by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to
` � � Registration Number
Name of Funeral Home itva 1, tl� . •
"> Address 67 Park Street
Cans Fails, N.Y. 12601
'><'> Name of Funeral Firm Making Disposition or to Whom
R• emains are Shipped, If Other than Above
41 A• ddress
f
aw
iiN Permission is hereby granted to dispose of the human remain escribed above as indicated.
11 Date Issued 0//�J1'tr4, Registrar of Vital Statistics (=y4,4 _, CK7((-keirL-4...‹,_}
24--`` (signature)
>':. District Number SI0 i+ Place 6 )<y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
!r-
wDate of Disposition 7/14/94 Place of Disposition Pine View Cemetery Oueensbury NY 12804
W (address)
th Mohican 70-D 1
CC (section) (lot number) (grave number)
QName of Se r Person in Charge of Premises Rodney G. Mosher
g (please print)
I! Signatur Title Supt .
DOH-1555 (10/89) p. 1 of 2 VS-61