Chadwick, Ellen Marie @- # 3‘,2._
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Ellen Marie Chadwick Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/27/2022 78 Years War or Dates
F— Place of Death Hospital,Institution or
Z City,Town or Village Moreau Town Street Address 1031 Saratioga Road, Moreau Town, New York 12831
W
1p Manner of Death EI Natural Cause IllAccident ❑Homicide Suicide Undetermined Pending
Circumstances Investigation
W▪ Medical Certifier Name Title
C John Pezzulo DO
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed Town Of Moreau District Number Register Number
City,Town or Village 4562 20
HBurial Date Cemetery,Crematory or Facility Name
04/29/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or Held
p
and/or Hold Address
N
0
O. Date Point of
Ci)OTransportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
❑Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
IX
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/29/2022 Registrar of Vital Statistics Leeann 9Kc ca6e(ECectronicaCCy Signed)
(signature)
District Number 4562 Place Town Of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z ;� 1' -
LLIZ Date of Disposition II In I ZZ Place of Disposition --4 !��/i� Zri---Or�.�
,2 (address)
W
Cl)Q (section) (lot number) (grave number)
GName of Sexton or Person in Charge of Premises Ilir-Av<k4
Z ease print)
W Signature le - Title f
Olt!fi140
r`
DOH-1555(018)p 1 of 2
" Ain
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#