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Godlewski, Chester Anthony ..41.. it 2 2 NEW YORKSTATE DEPARTMENT OF HEALTH — errhit Bureau of Vital Records Burial Transit P Name First Middle Last Sex Chester Anthony Godlewski Male Date of Death Age If Veteran of U.S.Armed Forces, 02/23/2021 73 Years War or Dates F. Place of Death '1-` , Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital LU O Manner of Death © Natural Cause D Accident ❑Homicide El Suicide ❑Undetermined Pending ILI Circumstances Investigation W Medical Certifier Name Title O Zofia Drzymalski MD Address 1667 Elizabeth Street,Schenectady, New York 12303 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 117 ❑Burial Date Cemetery,Crematory or Facility Name 02/26/2021 Pine View Crematory El Entombment Address X❑Cremation Queensbury Town,New York ❑Donation g0Removal Date Place Removed and/or and/or Held H Hold Address W 0 N ❑Transportation Date Point of ITS Common Shipment Carrier Destination Date Cemetery Address El Disinterment ElReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077 Address 123 Main St,Argyle,New York 12809 Name of Funeral Firm Making Disposition or to Whom i-. Remains are Shipped,If Other than Above g Address CC al aPermission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/26/2021 Registrar of Vital Statistics Wpbert Andrew Curtis(E(ectronica((ySigned) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: /� I— -`tom / W Date of Disposition 311 Zi Place of Disposition Rh....— (address) W N (section) n (lot number) (grave number) ip,O Name of Sexton or Person in Charge of Premises f,• N4�t Z (pl a print) • Signature 7 Title fitiV`C DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 014591 Receipt • Human remains of 3 } ' ' delivered on , 20 1 �� Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#