Loading...
Burgess, Chester Warren NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vitat Records Name First Middlt?' Last Sex Chester Warren Burgess Male Date of Death Age If Veteran of U S.Auned F 07/07/2021 99 Years War or Dates k1P11r F.— Place of Death{ H pital,Institution or WCity,Town orVillage Chester Town Warren Street Address 14 Pine Lane,Chester Town Warren, New York 12817 p Manner of Death ©Natural Cause ❑Accident El Homicide ❑Suicide ❑Undetermined ❑Pending UCircumstances Investigation 0 Medical Certifier Name Title Lynn Keil PA Address 1340 State Route 9,Lake George Town,New York 12845 Death Certificate Filed District Number Register Number City,Town or Village Chestertown 5652 11 ❑Burial Date Cemetery,Crematory or Facility Name 07/08/2021 Pine View Crematory ❑Entombment .- -s$. X❑Crematii n • % ..ury Town,New York r ❑Donation 'ma's Z -"`'.Tate Place Removed l and/or Held and/or P. N Hold Address 0 Cl) �Transportation Date Point of p by Common Shipment Cartier .5',% Destination Disinterment Date Cemetery Address .,' Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander Baker Funeral Home 00037 Address 3809 Main St,Warrensburg,New York 12885 Name of Funeral Firm Making Disposition or to Whom 1- Remains are Shipped,If Other than Above 2 Address CC W 44' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 07/08/2021 Registrar of Vital Statistics Windy Conway(ECectronicalrySigned) (signature) F.' . District Number 5652 Place Chestertown, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: F' Z Date of Disposition -wilt' Place of Disposition r`V 7`__ 40.-.....-- W 2 (address) W Cl) CC (section) (lot number) (grave number) gName of Sexton or Person in Charge of Pre ises /! fctrQ L S of r�l Z (pleas LLI Signature /� T Title �FZ(jr►"'�}�1� DOH-1555(07/18)p 1 of 2 1 Public Health Law Sec. 4145(2b) 01 4 , 1 t Recei 1 P Human remains of delivered on , 20 1 1 1 1 1 .: 1 Pine View Cemetery Representing the funeral home named on burial permit 1 Official Funeral Directors Reg.or License# y 1