Cibble, Earle NEW YORK STATE DEPARTMENT OF HEALTH ` - ' # qb
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Earle Chadwick Dibble Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 20,2013 86 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 45 Needle Park Circle
Manner of Death X Natural Cause n Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
:g Medical Certifier Name Title
O. Daniel Way
Address
HH1IN,North Creek,NY 12853
• Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 ��y `
❑Burial Date Cemetery or Crematory
0 Entombment February 21,2013 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
9. and/or Address
1.:: Hold
ca
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
• a Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
Ik%►: Remains are Shipped, If Other than Above
Address
1tl
i Permission is hereby granted to dispose of the human re ains described above as indicated.
1
_� Date Issued c�tZ ) Registrar of Vital Statistics G\8/i-�,...._
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Place of Disposition CM"c ('
W Date of Disposition Z-lS-t3 p rt r,��%
2 (address)
W
Le (section) (lit number (grave number)
o• Name of Sexton or Person in Charge of Premises AI likpir • [ti
ZdiL please print)
W Signature Title C V.AE 63tlTOhL
(over)
DOH-1555 (02/2004)