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Spirowski Jr, Chester NEW YORK STATE DEPARTMENT OF HEALTI4 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Chester John Spirowski Jr. Male Date of Death Age If Veteran of U.S. Armed Forces, December 8, 2015 69 War or Dates FPlace of Death Hospital, Institution or W City, Town or Village Glens Falls Street Address Glens Falls Hospital fiji Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide n Undetermined ❑ Pending C Circumstances Investigation W Medical Certifier Name Title CI John Stoutenberg MD, M.D. Dr. Address 102 Park St. Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village 5601 ❑Burial Date Cemetery or Crematory December 9, 2015 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address H Hold Date Point of ❑Transportation Shipment fn by Common Destination CI Carrier ❑ Disinterment Date Cemetery Address Date Cemetery Address El Reinterment 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 I-- Remains are Shipped, If Other than Above M Address W Permission is hereby granted to dispose of the human remains scribed above as in ate . Date Issued 7 Registrar of Vital Statistics e 'per., �� e�: _ .; (signature) District Number 5601 Place \. 747- —0,d (7 I certify that the remains of the decedent identified above were disposed of in accordance h this permit on: I- W Date of Disposition 12/09/2015 Place of Disposition Quaker Road Queensbury,NY 12804 M (address) W co r (section) / (lot number) (grave number) aName of Sexton or Person in Charge of Premises 14nth�J' S,MHo Z d (pl ase print) W` Signature Title C►4)Ialit (over) DOH-1555 (02/2004)