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Chamberlain, Harriet L. NEW YORK STATE DEPARTMENT OF HEALTH : r. Burial - Transit Permit'Bureau of Vital Records " Name First Middle Last Sex 4 Harriet L.Chamberlain Female 4:1- Date of Death Age If Veteran of U.S.Armed Forces, N¢ 09/26/2020 75 Years War or Dates F Place of Death Hospital,Institution or W City,Town or Village Albany Street Address Albany Medical Center Hospital p Manner of Death ©Natural Cause 1=1 Accident El Homicide ❑Suicide ❑Undetermined El Pending UCircumstances Investigation LU Medical Certifier Name Title Amanda Custozzo Address 43 New Scotland Ave,Albany,New York 12208 '= Death Certificate Filed District Number Register Number City,Town or Village Albany 0101 2032 v Ei Burial Date Cemetery,Crematory or Facility Name 09/30/2020 Pine View Crematory ' ❑Entombment Address X❑Cremation Queensbury Town,New York 1-1 Donation Z Date Place Removed Removal 0 and/or and/or Held Hold Address 0 O. Date Point of CO LI Transportation C by Common Shipment Carrier 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 -. Remains are Shipped,If Other than Above 2 Address CC 10'J a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/29/2020 Registrar of Vital Statistics (Danie(CeSCiCCespie(ECectronicaCCySigned) (signature) District Number 0101 Place Albany, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: F- 4._ W' Date of Disposition 1130 f ZoPlace of Disposition ?..../.....2 ddress) ILI CO Ce (section) (lot umber) (grave number) 2` Name of Sexton or Person in Charge of r ises .w�b �Hv{)0 Z pleaseMint) LLI Signature Title tY{ [ DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 1 Receipt 1 Human remains of , , �� delivered on 1 .� f , 20 " Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# ,-�•,, ,r