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Chapman, Alyson Gail - 1 , (I'll NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records II l Name First Middle • Last Sex Alyson Gail Chapman Female Date of Death Age If Veteran of U.S.Armed Forces, o, 06/13/2021 37 Years War or Dates ▪ Place of Death Hospital,Institution or W • City,Town or Village Glens Falls Street Address Glens Falls Hospital CI Manner of Death ©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending ✓ Circumstances Investigation W Medical Certifier Name Title CI William Cleaver MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 247 ❑Burial Date Cemetery,Crematory or Facility Name 06/15/2021 Pine View Crematory ❑Entombment Address 0 Cremation Queensbury,New York ❑Donation Z Removal Date Place Removed and/or and/or Held N Hold Address 0 O. 1-1 Date Point of co Li Transportation b by Common Shipment Carrier Destination Date Cemetery Address y9❑Disinterment 4 Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 2 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/15/2021 Registrar of Vital Statistics q&6ertAndrew Curtis(Electronically Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition (olilul 14 Place of Dispositions Ufa 40(1----- 2 (address) W LC LC (section) tot number) (grave number) 0 Name of Sexton or Person in Charge of Premises r 4 iND _. 5:►A.�l4 z C (Please riot/ W Signature c Title tire— DO H-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) n'" /1 8 h Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#