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Chartrand, Ronald Walter -t 100 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Ronald Walter Chartrand Male Date of Death Age If Veteran of U.S.Armed Forces, 11/23/2021 89 Years War or Dates 51-55 Place of Death Hospital,Institution or Z Ili City,Town or Village Kingsbury Town Street Address 396 Queensbury Avenue,Kingsbury Town,New York 12839 0 Manner of Death ©Natural Cause ❑Accident D Homicide ❑Suicide ❑Undetermined 0 Pending W0 Circumstances Investigation W Medical Certifier Name Title C Christopher Mason DO Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Kingsbury Town 5762 22 . 0 Burial Date Cemetery,Crematory or Facility Name 11/26/2021 Pine View Crematory Entombment Address X❑Cremation Queensbury,New York ❑Donation Z❑Removal Date Place Removed and/or and/or Held }= Hold Address N 0 ta. Date Point of (I') ❑Transportation Shipment C by Common Carrier Destination Date Cemetery Address ❑Disinterment ❑Re interment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address .W t3 Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/24/2021 Registrar of Vital Statistics Cynthia Bare in(ECectronicaffy Signed) (signature) District Number 5762 Place Kingsbury Town, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition I 11.411( Place of Disposition n(V� r= 2 (address) W Ncc (section) (lot number) (grave number) �--- 8 Name of Sexton or Person in Charge of r mises (t7 `�tv1 z �2 (please print) {� III Signature e% Title _ (2'"vli DOH-1555(07/18)p 1 of 2 a5 3E7 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#