Chatterton, Randy . 4t ly2
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Randy V. Chatterton Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 26, 2015 62 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address 43 Haskell Ave
• Manner of Death I�I Natural Cause I I Accident n Homicide Suicide I I Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Michael Adams,MD
Address
1448 Route 9,Warrensburg,NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601 i
❑Burial Date Cemetery or Crematory
3/3/2015 Pine View Crematory
❑Entombment Address
❑x Cremation 51 Quaker Rd., Queensbury NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
Nn Transportation Shipment
'p by Common Destination
Carrier
Disinterment Date Cemetery Address
C Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
M Address w
rd
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 2)2.. 7 l/5 Registrar of Vital Statistics (,n.) Gl w
(sign
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W , Urr,, �°
.,• Date of Disposition 3)31t Place of Disposition ,1 C�-4- efor .-
W (address)
U)
(section) (Jot number) (grave number)
QName of Sexton or Person in Charge of Premises tr.� r enr
Z ( lease print)
W
Signature Title ((ti' M 'j7rL
(over)
DOH-1555(02/2004)