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Chatham, Sr. Charles NEW YORK STATE DEPARTMENT OF HEALTH 'cv.$Eri( Vital Records Section Burial - Transit Permit Name First Middle Last I Sex Charles T. Chatham, Sr. j Male Date of Death Age I If Veteran of U.S. Armed Forces, November 27, 2011 83 War or Dates World War II i... Place of Death ; Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital el Manner of Death I XI Natural Cause I I Accident f I Homicide Suicide Undetermined Pending iiiCircumstances Investigation Medical Certifier Name Title P. Farhana Kamal,MD Address Park St, Glens Falls,NY Death Certificate Filed District Number Reqn tuber City, Town or Village Glens Falls 5601 ❑Burial Date Cemetery or Crematory III Entombment November 29, 2011 Pine View Crematorium Address ©Cremation 21 Quaker Road, Queensbury, NY 12804 Date Place Removed Z I I Removal and/or Held 0 and/or Address N Hold 0 Date Point of NI I Transportation Shipment `p by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan& Denny Funeral Home 01443 Address 53 Quaker Road, Queensbury,NY 12804 Name of Funeral Firm Making Disposition or to Whom ;k ` Remains are Shipped, If Other than Above X Address 1 . W13. Permission is hereby granted to dispose of the human remains desc ibed abo as ' i ated. . Date Issued ///2r/lo// Registrar of Vital Statistics ` � signature) District Number 5601 Place Glens Falls I certify that the remains of the decedent identified above were disposedd of in accordance with this permit on: LUDate of Disposition � 1 t 7Oil Place of Disposition um Vat.; C- 1dt bu� W (address) N ix (section) (I t number) (grave number) ci Name of Sexton or Person in Charge of/remises 4n3 ceiwit- z please print) WZif Signature L Title Cps ni 0e. (over) DOH-1555(02/2004)