Chadwick, Jason NEW YORK STATE DEPARTMENT OF HEALTH I•f 51.3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jason Paul Chadwick Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 31, 2012 37 War or Dates
I Place of Death Hospital, Institution or
WZ City, Town or Village Queensbury Street Address 18 Barton Place
Ci
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
UJ
Circumstances Investigation
W' Medical Certifier Name Title
Paul Bachman, M.D.
Address
3767 Main Street Warrensburg, NY 12885
Death -rtificate Filed f District Number Register Number
City, I own • Village 0••{61S .7%-4''y �(9 S ' y r
El Burial Date ( Cemetery or Crematory
November 5, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
p and/or Address
p Hold
0) Date Point of
eL ❑Transportation Shipment
OD by Common Destination
C1 Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ 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
F- Remains are Shipped, If Other than Above
2' Address
ft
WCL`
Permission is hereby granted to dispose of the human re ai s described above as i dic' ted.
Date Issued (f (2, i 1. Registrar of Vital Statistics 04,1_ A
(signature)
District Number 3117 Place w1 ce- a,ewu 6.✓y � 1 b/) . o csii
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iii Z Date of Disposition p C
p ((� t2 Place of Disposition kt., Dior,vr--
W (address)
CO
IX (section) . (lot number) (grave number)
inName of Sexton or P rson in Char a of Premises /111(l �rh�,(¢
Z lease print)
W Signature — Title AO M r.-L.D
(over)
DOH-1555 (02/2004)