Chatelle, Edwin NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Edwin W. Chatelle Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 7, 2013 61 War or Dates
F„ Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Sheet Address Glens Falls Hospital
GManner of Death (Natural Cause Accident n Homicide El Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Nam Title
G )I-. L Akii8L. C OY\ ti P
Address
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 1 41
❑Burial Date Cemetery or Crematory
January 9, 2013 Pine View Crematorium
❑Entombment Address
El Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z 0 Removal and/or Held
and/or Address
H Hold
N
O Date Point of
u) Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
n 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
F- Remains are Shipped, If Other than Above
EAddress
! l
a
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 / 9 1 l 3 Registrar of Vital Statistics W C - LA)
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �
w Date of Disposition f-IO,t.3 Place of Disposition r[,..,Ut'40) Lr&tr ld f ifo A.-
L (address)
W
CO
Qr (section) 4 hot number) (grave number)
Q Name of Sexton or Person in Charge of Premises 6 yit�) itJ r thp/((
W (please print)
Signature Title aft')4ldt
(over)
DOH-1555(02/2004)