Chapman, Webster 11 NEW YORK STATE DEPARTMENT OF HEALTH! . % # 5-
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Webster L. Chapman Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 30, 2012 45 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address
Manner of Death Natural Cause ❑ Accident ❑ Homicide n Suicide ❑ Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Darci Ann Gaiotti-Grubbs, M.D Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register tuber
City, Town or Village s t<14 L J
❑Burial Date Cemetery or Crematory
October 2, 2012 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
Hold
Date Point of
nTransportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 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
8a
Permission is hereby granted to dispose of the human remai s desciibendnnab v ' dicate
Date Issued to 2 Z____ Registrar of Vital Statistics
/� (signature)
District Number 5"�Sc Place
..
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�� Date of Disposition 10/02/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
II
(section) /j - (lot number)r' (grave number)
Name of Sexton or Person i Charge of remises Ghe'.S J1,w- "
please print)
�. Signature Title C i2
(over)
DOH-1555 (02/2004)