Chamberlain, Katherine NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records ' `
Name First Middle Last Sex
Katherine Chamberlain Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/28/2021 74 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Saratoga Springs Street Address Saratoga Hospital
p Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Pending
UCircumstances Investigation
WQ Medical Certifier Name Title
Jennifer White DO
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village litaratoga Springs 4501 312
❑Burial Date Cemetery,Crematory or Facility Name
06/01/2021 Pine View Crematory
❑Entombment Address
0 Cremation Queensbury Town,New York
❑Donation
0 ElRemoval Date Place Removed
and/or and/or Held
— Hold Address
1-1
O
a Date Point of
N ❑Transportation
CI Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home Inc 00211
Address
24 Church Street PO Box 500,Lake Luzerne, New York 12846
Name of Funeral Firm Making Disposition or to Whom
F. Remains are Shipped,If Other than Above
a Address
CC
W
C" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/01/2021 Registrar of Vital Statistics John Paul Franck(Electronically Signed)
(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 on:
I_
W Date of Disposition 101 Z I'll Place of Disposition ', V�„� 4°."-
2 (address)
W
N
CC (section) (lot numb (grave number)
GName of Sexton or Person in Charge of Pr ises �% r•1 �--5w�„ 4t-
Z Z11
(please print)Signature Title it tOt
DOH-1555(07/18)p i of 2
Public Health Law Sec. 4145(2b) i - 1 « 014822
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# / x