Chapman, Margery NEW YORK STATE DEPARTMENT OF HEALTH LKg
Vital Records Section — a Burial - Transit Permit
Name First Middle Last Sex
Margery T. Chapman Female
Date of Death Age If Veteran of U.S.Armed Forces,
F, November 6, 2006 63 War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Hartford Street Address Own Home
0 Manner of Death 0 Natural Cause n Accident D Homicide (Suicide 0 Undetermined 0 Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W Dr. Mark Hoffman Dr.
0 Address
420 Glen Street, Glens Falls, NY 12801
Death Certificate Filed District Number Si5� Register Number,,.,
City,Town or Village Hartford cL
❑Burial Date Cemetery or Crematory
November 8, 2006 Pine View Crematory
❑Entombment Address
❑▪ X Cremation Quaker Road Queensbury, NY 12804
2 Date Place Removed
0 0 Removal and/or Held
and/or Address
I' Hold
0 Date Point of
4 0 Transportation Shipment
A by Common Destination
i Carrier
Date Cemetery Address
a▪ 0 Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01140
Address
123 Main St. , Argyle, New York 12809
~ Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
IX
W Address
O.
Permission is hereby granted to dispose of the human remains d ribecabove: indicated.
Date Issued _ 11\-)\OL9
Registrar of Vital Statistics
(signature)
District Number 5---)5C\ Place Hartford,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition 11/08/2006 Place of Disposition Pine View Crematory
2 (address)
W
(II
O (section) (lot number) (grave number)
00 Name of Sexton or Person in Charge of Premises CI. c) S Son nt'+t
W / �+ (please print)
Signature (�' /�2,v,v, --- Title L,r'r r cAtc�r
(over)
DOH-1555 (02/2004)