Loading...
Dewey Jr, Chalmers j # (,1 0 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Chalmers B. Dewey,Jr. Male Date of Death Age If Veteran of U.S. Armed Forces, November 11,2013 85 War or Dates t- Place of Death Hospital, Institution or Z City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home © Manner of Death 0 Natural Cause EI Accident 0 Homicide n Suicide n Undetermined Pending W Circumstances Investigation W Medical Certifier Name Title G Charlene Harrington PA Address 327 Broadway,Fort Edward,NY 12828 Death Certificate Filed Fort Edward District Number Register Number City,Town or Village 5755 lg ❑Burial Date Cemetery or Crematory November 13, 2013 Pine View Crematorium Entombment Address ®Cremation 21 Quaker Road,Queensbury,NY 12804 Date Place Removed ZZ C Removal and/or Held and/or Address E Hold N O Date Point of NE Transportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address DReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Road,Queensbury,NY 12804 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped, If Other than Above 2 Address Ir W O. Permission is he eb granted to dispose of the human r ains described above indicated. Date Issued//j� /3 Registrar of Vital Statisti ,/,f7Q,s0 (signature) District Number 5755 Place Fort Edward I certify that the remains of the decedent identified above were disposed' of in accordance with this permit on: W Date of Disposition//lv'/3 Place of Disposition �jti4 V'i'.✓ CE,C-h-04,4"—(7 2 (address) W U) O (section � ��lot nu ber) (grave number) pName of Sexton or er on ' rge of Premises G Z (please print), JJ W Title �� T. Signature `.- -- (over) DOH-1555(02/2004)