McLain, Chester NEW YORK STATE DEPARTMENT OF HEALTH -I ` !
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Chester L. McLain Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 12,2014 88 War or Dates World War II
Place of Death Hospital, Institutiorjirondack Tri-County Health Care
City, Town or Village Johnsburg Street Address Center
:tea Manner of Death I X]Natural Cause ( 1 Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
Au Medical Certifier Name Title
James Hindson MD
Address
Main St.,Warrensburg,NY 12885
Death Certificate Filed District Number . 65C Register Number
City, Town or Village Johnsburg 4111411111at S
❑Burial Date Cemetery or Crematory
Entombment January 15,2014 Pine View Crematory
Address
Ili Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
OI I Removal and/or Held
and/or Address
E Hold
N
0 Date Point of
N I 'Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
I
I Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
._' Address
3809 Main Street, Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
tom Remains are Shipped, If Other than Above
Address
VI
Permission is hereby granted to dispose of the human rema' scribed above as indica ed.
Date Issued 1-15-14 Registrar of Vital Statistics
(signature)
District Number 5601 Place T/O Johnsburg,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LuDate of Disposition /-11.114 Place of Disposition Z
W (address)
Cl)
Z0 (section) (lo number) (grave number)
Name of Sexton or Perso in Charge of Premises s, i- — �" -'
( lease print)
W
L-_
Signature Title `'aVewtyliWt
(over)
DOH-1555 (02/2004)