Chapman, Shirley 3Z2
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Shirley Chapman F
Date of Death Age If Veteran of U.S. Armed Forces,
05/19/2014 70 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
ILIManner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
t Medical Certifier Name Title
0 Gamal Khalifa MD
Address
100 Park Street Glens Falls,NY 12801 '
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 560/ Z 33
❑Burial Date Cemetery or Crematory
05/20/2014 Pineview Crematory
['Entombment Address
[ICremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z ❑Removal and/or Held
2 and/or Address
H Hold
ma
0 Date Point of
L' 0 Transportation Shipment
C by Common Destination
Carrier
❑Disinterment Date _ Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home MB Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward,NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
I
I
a Permission is hereby granted to dispose of the human remains descr"bed abov as' ' ted.
Date Issued 031/W20/V Registrar of Vital Statistics 4/ -
(signature)
District Number , ‘,„0/ Place '7 ,AA, /ty
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 5/to(H Place of Disposition ,atioF,., f,c,...
2 (address)
LU
IC (section) (lot number)J!nNtt
(grave number)
CI Name of Sexton or Person in Charge of Premises '"37
Z ( ease print)
1 Signature Title L'2�=�`�1Sdfr
(over)
DOH-1555 (02/2004)