Morehouse, Chauncey NEW YORK STATE DEPARTMENT OF HE H • z J G(
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Chauncey Daniel Morehouse Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 8, 2011 62 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause ID Accident Homicide Suicide Undetermined Pending
II Circumstances Investigation
W Medical Certifier Name Title
in Paul Bachman, M.D.
Address
3767 Main Street Warrensburg, NY 12885
Death Certificate Filed District Number Registe�fber
City, Town or Village 5601 JJ``
❑Burial Date Cemetery or Crematory
10/11/2011 Pine View Crematorium
.0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Z El
Removal and/or Held
and/or Address
j Hold Pine View Crematorium
Date Point of
0. El Transportation Shipment
(1) by Common Destination
ICI Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
- Remains are Shipped, If Other than Above
2 Address
w
O.. Permission is hereb granted to dispose of the human remains de c ibe ab a as ' i ated.
Date Issued /O //A 2OI/ Registrar of Vital Statistics `G �
(signature)
District Number 5601 Place 67�..o -‘, / 7'
I—' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
uj Date of Disposition 10'"1?'doff Place of Disposition (ine u.'e44; ( f 1^L. 1
(address)
tills,'
(1)
(section) `I !� �,(lot number) (grave number)
Z Name of Sexton or Person in Charge o Premises I O'''104`�1y Wf Melee
--- (please print)
W' Signature Title cre41c1/4,1`cr7 1A-5.s74-
(over)
DOH-1555 (02/2004)