Chapman, Charles NEW YORK STATE DEPARTMENT OF HEALTH fry I
Vital Records Section 4 • li Burial - Transit Permit
Name First Middle Last Sex
Charles M. Chapman Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 26, 2011 57 War or Dates
Place of Death Hospital, Institution or
City, Town or Village South Glens Falls Street Address 5 Adams Road
.1: Manner of Death 0 Natural Cause D Accident 0 Homicide 0 Suicide Undetermined El Pending
1$T
Circumstances Investigation
." Medical Certifier Name Title
Gerald Abess, Dr.
Address
3 Irongate Center Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 434-2- • .2-
0 Burial Date Cemetery or Crematory
January 31, 2011 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
Shipment
�I� Transportation
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 01098
Address
82 Broadway, Fort Edward NY 12828
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 remain described above indicated.
Date Issued /— 'J0// Registrar of Vital Statistics y) plc-�u� gi i5 - c
(signature)
District Number �!C Place / •
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 01/31/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot numb (grave number)
Name of Sexton or P r on in Charg f Premises (1/n si-cVLr 3e h. '
(please print)
Signature _ 40pL. Title 01E 6 ti rot
(over)
DOH-1555 (02/2004)