Chapman, Robert ill
ttig
NEW YORK STATE DEPARTMENT OF HEALTH 1 g°
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert J. Chapman Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 27, 2015 77 War or Dates
Place of Death Hospital, Institution or
ili City, Town or Village Glens Falls Street Address Glens Falls Hospital
• Manner of Death Natural Cause 111 Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
WCircumstances Investigation
W Medical Certifier Name Title
Paul F. Bachman,
Address
3767 Main Street Warrensburg, NY 12885
Death Certificate Filed District Number__ Register Wc" r
City, Town or Village Glens Falls �� �J
0 Burial Date Cemetery or Crematory
October 29, 2015 Pine View Crematory
'';❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
0 and/or Address
Hold
W Date Point of
0. ❑Transportation Shipment
O by Common Destination
• Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home-Argyle 01077
Address
123 Main St., Argyle NY 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Lk` Permission is hereby granted to dispose of the human remains described abovetas indicated.
Date Issued yv , Z.c, 16 Registrar of Vital Statistics l..A)C
t- (signature
District Number 5 60, Place 6 F .f C. ,\ S , kU k)
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 10/29/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
Ui
CO
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises ��ro Jtrt,u�
Ili
( lease print)
Signature Title 112444491
(over)
DOH-1555 (02/2004)