Chapman, Marilyn O 0n l
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Marilyn Chapman Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/30/2020 92 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Saratoga Springs Street Address Wesley Health Care Center Inc
`p Manner of Death Ei Natural Cause ❑Accident Homicide ❑Suicide ElUndetermined ElPending
U Circumstances Investigation
W Medical Certifier Name Title
CI Pamela Casey NP
Address
131 Lawrence St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village' Saratoga Springs 4501 700
❑Burial Date Cemetery,Crematory or Facility Name
12/31/2020 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury,New York
ElDonation
Removal Date Place Removed
and/or and/or Held
N Hold Address
0
d Date Point of
Cl) ❑Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care Inc 00364
Address
402 Maple Ave,Saratoga Springs,New York 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/31/2020 Registrar of Vital Statistics ,Join PaulFranckgkctronica,65,Srgned)
(signature)
District Number 4501 Place Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit
Z Date of Disposition 11 ttg Place of Disposition
111 (address)
W
CC U)
(section) lot number) (grave number)
gName of Sexton or Person in Charge of Premis �)t�° � n tiff
(please pfbt)
w Inedf"friPt
Signature Title
DOH-1555(07/18)p i of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#