Chadwick, Margaret r ., t ft ?II
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
mi. Name First Middle Last Sex
s>' Margaret Martha Chadwick Female
Date of Death Age If Veteran of U.S. Armed Forces,
`< September 27, 2016 72 War or Dates
`'%- Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 5 Hummingbird Lane
Manner of Death a Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Darci Gaiotti-Grubs,MD
Address
q. Glens Falls,NY
W. Death Certificate Filed District Number Regist umber
fM;
,,,:a City, Town or Village Queensbury, NY 5657 1 1
0 Burial Date Cemetery or Crematory
❑Entombment October 3,2016 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z ❑Removal and/or Held
and/or Address
H Hold
ti)
0 Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Renterment Date Cemetery Address
>, Permit Issued to Registration Number
'`2; Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
'- Address
iM
i 407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
` Remains are Shipped, If Other than Above
Address
: s
Permission is hereby granted to dispose of the human re ains described above s indicatted.
<£% Date Issued I c�5,t ken Registrar of Vital Statistics q, C (1.1.....,,...
^_ (signature)
gA
j District Numbe(s ) Place 1 �? u..rTh 6 -c
I certify that the remains of the decedent identified above were disposed of in acco ce ith this permit on:
W Date of Disposition J('(Ijb Place of Disposition RAIN, Cetinr t',
W (address)
U)
to (section) Aet
(lotnumber)c- (grave number)
pName of Sexton or Person in Charge of Premises I r- S,^lL4
W (pkase print)
Signature aTitle (f'E M' h
(over)
DOH-1555(02/2004)