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Chabot, Henry Coy l ! 862 1 NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Henry Coy Chabot Male Date of Death Age If Veteran of U.S.Armed Forces, 12/23/2019 83 Years War or Dates H Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address Corinth Road,Queensbury Town,New York 12804 p Manner of Death Natural Cause ©Accident Homicide Suicide Undetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title Paul Bachman MD Address 9 Carey Rd,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 195 ❑Burial Date Cemetery,Crematory or Facility Name 12/28/2019 Pine View Crematorium Entombment Address WICremation Queensbury Town,New York Donation OZ ❑Removal Date Place Removed and/or and/or Held F-N Hold Address O (L Date Point of (n Transportation Shipment p by Common p Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom II.- Remains are Shipped,If Other than Above Address cc W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/27/2019 Registrar of Vital Statistics Carofine76fifegarde Barber(ECectronicaCCySigned) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H W Date of Disposition % - / Place of Disposition R. C address/ 2 W N (section) lot n mber) (grave number) 16,) 0 Name of Sexton or Person in Charge of Prerm s ' �' Z (please print) W Signature Title © r DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 013186 Receipt Human remains of delivered on !. , 20 ,f Pine View Cemetery ReIiiesenting the funeral home named on burial permit Official Funeral Directors Reg.or License#