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Tennyson, Walter John
NEW YORK STATE DEPARTMENT OF HEALTH 1 Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Wafter John Tennyson Male Date of Death Age If Veteran of U.S.Armed Forces, 11/07/2019 81 Years War or Dates F Place of Death Hospital,Institution or wClty,Town or Village Chester Town Warren Street Address 15 Panther Mt Drive Ext,Chester Town Warren,New York 12817 Mannerof Death ©Natural Cause El Accident Homicide Suicide Undetermined Pending Circumstances Investigation Medical Certifier Name Title Janine Gadjo NP Address 9 Carey Road,Queensbury Town,New York 12804 F eath Certificate Filed District Number Register Number ity,Town or Village Chestertown 5652 18 ❑Burial Date Cemetery,Crematory or Facility Name 11/08/2019 Pine View Crematorium Entombment Address 0 Cremation Queensbury Hamlet,New York ❑Donation z Date Place Removed 0❑Removal and/or and/or Held NHold Address 0 ❑Transportation Date Point of p by Common Shipment Carrier Destination Disinterment Date Cemetery Address 10 Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141 Address 9 Pine St,Chestertown,New York 12817 Name of Funeral Firm Making Disposition or to Whom (- Remains are Shipped,If Other than Above 2 Address cc Uj a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/08/2019 Registrar of Vital Statistics Windy Conway(ECectronicalTySiywd) (signature/ District Number 5652 Place Chestertown, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 1-W Date of Disposition I111 Ili Place of Disposition ,�,�„ C/�4' (address) W tiC (sectron/ (tot number/ (grave number) Name of Sexton or Person in Charge of Premises z (p ase print) iU Signature Title L DO H-1555(o7/t8)p 1 of 2 f• Public Health Law Sec. 4145(2b) 0 1 3 0 6 6 Receipt Human remains of delivered on `` , 20 Pine View`Cemetery' ;` Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# r.