Chapin, Jean 0 0-7
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section • Burial - Transit Permit
Name First Middle Last Sex
Jean M. Chapin Female
;- Date of Death Age If Veteran of U.S. Armed Forces,
November 3,2013 92 War or Dates
Place of Death Hospital, Institutiorfl fe Stanton Nursing& Rehabilitation
: City, Town or Village Queensbury Street Address Centre
;a Manner of Death n Natural Cause Accident Homicide Suicide Undetermined Pending
` : Circumstances Investigation
Medical Certifier Name Title
0 Susan Blood
Address
14 Manor Drive,Queensbury,NY 12804
. Death Certificate Filed District Number Register Num er
.' City, Town or Village Queensbury 5657 `>
❑Burial Date Cemetery or Crematory /
❑ November 8,2013 Pine View Crematory
Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z 1 I Removal and/or Held
and/or Address
H Hold
co
0 Date Point of
N n Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
3 �
: Permit Issued to Registration Number
>- Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
l* Remains are Shipped, If Other than Above
Address
a _
Permission is hereby granted to dispose of the human mains described abo as indicated.
Date Issued /f— 5--2o)3 Registrar of Vital Statistics
(signature)
District Number 5657 Place Queensbury
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of DispositionN-A)73 Place of Disposition ANC V/ J C#161 '
W (address)
CO
re
(section) � (lot number) (grave number)
pName of Sexton o Per on i rge of Premises s^ XpLI/
Z �/ please print)
w Signature J� /S Title Title
(over)
DOH-1555 (02/2004)