Chamberlin, James - VI 71(
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
' Name First Middle Last Sex
:;r; James S. Chamberlin Male
ti;::: Date of Death Age If Veteran of U.S. Armed Forces,
iiiiii November 13, 2014 65 War or Dates
.: Place of Deathl Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
ig Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
+ Medical Certifier Name Title
gi, Noelle Stevens MD
j Address
▪s 100 Broad Street,Glens Falls,NY 12801
::: Death Certificate Filed District Number Register Number
.
City, Town or Village Glens Falls 5601 5 2.
❑Burial Date Cemetery or Crematory
November 17, 2014 Pine View Crematorium
❑Entombment Address
EI Cremation 21 Quaker Road,Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
Cl)
O Date Point of
WTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
iiiiii Address
;:j; 407 Bay Road, Queensbury, NY 12804
r:;; Name of Funeral Firm Making Disposition or to Whom
▪ Remains are Shipped, If Other than Above
Address
::s,.d Permission is hereby granted to dispose of the human remains described above as,indicated.
Date Issued M) d 1 -7 hit Registrar of Vital Statistics lam _
(signature
:*, District Number 5601 Place Glens Falls
rs,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z a
IL! Date of Disposition Ii /ic j i j Place of Disposition F,.s.��,, ..,.�,.,,
Ili
(address)
U)
0 (section) /j (lot number)( (grave number)
p• Name of Sexton or Person in Charge of Premisestiv, awl
Z �J lease print)
Signature CLIJI /i' �--�. Title lizpiwlj i
(over)
DOH-1555(02/2004)