Chapin, Daniel NEW YORK STATE DEPARTMENT OF HEALTH 4 WA'
Vital Records Section c _ t Burial - Transit Permit
Name First Middle Last Sex
Daniel George Chapin Male
Date of Death Age/ If Veteran of U.S. Armed Forces,
ay July 24, 2014 War or Dates
"" Place of Death Hospital, Institution or
City, Town or Village Fort Ann Street Address 1 Chapin Road
Manner of Death Natural Cause ❑ Accident ❑ Homicide 0 Suicide III Undetermined ri❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Ruth Scribner,
Address
55 Beckett Road Whitehall, NY 12887
Death Certificate Filed District Nu beri Register tuber
City, Town or Village Fort Ann
❑Burial Date Cemetery or Crematory
' July 25, 2014 Pine View Crematory
❑Entombment Address
vim,
®Cremation Quaker Road Queensbury,NY 12804
p-: Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
x ❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
y Name of Funeral Home M. B. Kilmer Funeral Home 01077
Address
vo 123 Main St., Argyle NY 12809
Name of Funeral Firm Making Disposition or to Whom
`Y a Remains are Shipped, If Other than Above
Address
Permission is her 7ran;edRtodipose of the hun rem ins described abdicategistrar of Vital Statistics /e4je_ � �
��''� („gnature)
District Number c5 767. Place a JQ t2- 7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 07/ 2014 Place of Disposition Quaker Road Queensbury,NY 12804 PN / Cm
(address) J'
/ (section) ,........1of number) (grave number)
Name of Sexto, or •ers„ i✓harge of Premises �6e/ pit) ) .CI
11 (please pri t)
Signature ' I '�fr / Title e. /c')•
(over)
DOH-1555 (02/2004)