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Chamberlain, Donald NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Donald G. Chamberlain Male Date of Death Age 1 If Veteran of U.S. Armed Forces, June 15, 2011 79 War or Dates No 14 Place of Death Hospital, Institution or Z City, Town or Village Glens Falls , Street Address Glens Falls Hospital ciManner of Death I X]Natural Cause n Accident I I Homicide 'Suicide Undetermined Pending Ul Circumstances Investigation us Medical Certifier Name Title Matthew Varughese Address 100 Park St,Glens Falls,NY 12801 Death Certificate Filed District Number Regisr ,.: City, Town or Village Glens Falls 5601 ❑Burial Date Cemetery or Crematory ❑Entombment June 16, 2011 Pine View Crematorium Address ©Cremation 21 Quaker Road,Queensbury,NY 12804 Date Place Removed ZZ ( 1 Removal and/or Held and/or Address H Hold N O Date Point of Nn Transportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address n Reinterment Date Cemetery Address I Permit Issued to Registration Number ::::; Name of Funeral Home Regan& Denny Funeral Home 01464 Address ::; 53 Quaker Road,Queensbury, NY 12804 Name of Funeral Firm Making Disposition or to Whom t+=, Remains are Shipped, If Other than Above S Address re Kt • Permission is here y granted to dispose of the human remains de ribed ab/ve dicated. Date Issued e6 /G 20// Registrar of Vital Statistics U`t (signature) District Number 56016 Place Glens Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ut Date of Disposition (0,tl-jn tr Place of Disposition (.?"7.e J,P..:! Cr,e muek.a r,;z3 i W (address) N tr (section)^� (lot number) (grave number) Q Name of Sexton or Person in Charge of Premises t r" p,,,o4�, 3c.n efr Z �� f (please print) W Signature _ gu..4,2,41 Title Cr-eqtory 055# . (over) DOH-1555(02/2004)