Chadwick, John NEW YORK STATE DEPARTMENT OF HEALTH 1-CF
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
John S Chadwick Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/28/2023 70 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 484 State Route 149 Apt.1,Queensbury Town,New York 12804
O Manner of Death El Natural Cause Accident Homicide Suicide FlUndetermined ElPending
W Circumstances Investigation
C) Medical Certifier Name Title
O Lynn Keil PA
Address
1340 State Route 9,Lake-GeorgeTawn,lVew ark iz845 - ----- --
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 70
I Burial Date Cemetery,Crematory or Facility Name
05/03/2023 Mt Hermon Cemetery
Entombment
_ Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
Date Point of
N ETransportation Shipment
S by Common
Carrier Destination
Disinterment
Date Cemetery Address
nDate Cemetery Address
LIReinterment
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
2 Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/02/2023 Registrar of Vital Statistics Caroline?filiegardC Barber(ECectronicallySigned)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z � , r af� ,
W Date of Disposition - so Place of Disposition (,t1Sf1 �� �.1.t2jt
(address)
LUi —irn-t• Irk e9,4 ,IkA rnO(-I-i n,101c jo-f "
resection) (tot number) (grave number)
gName of Sexton or Person in Charge of Premi es C / -\nn t C " c J2+
z444/. (please print)
W Signature , Title JUperl n Tom' `L��
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
012978
Receipt
Human remains of , yr<'; r ' , L. delivered on , 20S
rt
P t r
F
Pine View Cemetery, Representing the funeral home named on,buriia(permit
i Official ,�_' Funeral Directors Reg.or License# ' 'i ,, tt
CHADWICK /
NAME ):71.!!)
Age:
John Chadwick 70
Lot Owner: Martindale Lot
Lot# Martindale Lot Grave#
Case: Concrete
Died: 4.2 8.2 3 Interred: 5. 3.2 3
Funeral Home: Regan Denny Stafford
Cemetery: 1^)')r y)o/'%