Breen, Chastine NEW YORK STATE DEPARTMENT OF HEALTH I` S-e\_l Vital Records Section Burial - Transit Permit
T Name First Middle Last Sex
Chastine Breen Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 25, 2011 100 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Stanton Nursing & Rehabilitation Center
r Manner of Death El Natural Cause ❑ Accident ❑ Homicide ❑ Suicide Undetermined ri❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Roslyn Socolof, M.D. Dr.
Address
100 Broad Street Glens Falls, NY 12801
Y Death Certificate Filed District Number Re$ister Ner
. City, Town or Village 4 C n I oZ`
� Date Cemete or Crematory
❑Burial November 28, 2011 Pine View
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
I
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
# by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
" Address
136 Main Street, South Glens Falls NY 12803
`: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
' Address
Permission is hereby granted to dispose of the human remains described a v as indicated.
Date Issued t( 101 Ic3-0 11 Registrar of Vital Statistics ` . C G ,CJ (k,�
(signature)
District Number CpC Place ( 0 04. CD
1
I certify that the remains of the decedent identified above were disposed of in accora anceyth this permit on:
Date of Disposition 11/28/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
I
':: Name of Sexton or Person in Charge o Premises ► t�vrr r)4kle �3 runeIf
`g (please pent)
Signature Title Cr-ewe Gnrt_4314.
(over)
DOH-1555 (02/2004)