Loading...
Chaplin, Michael Andrew tt _ NEW YORK STATE DEPARTMENT OF HEALTHAllt �13 Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Michael Andrew Chaplin +ra " Male Date of Death Age If Veteran of U.S.Armed Forces, 10/03/2021 63 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village South Glens Falls Village Street Address 817 Riverview,South Glens Falls Village, New York 12803 W p Manner of Death © Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending W U Circumstances Investigation W Medical Certifier Name Title O Kathleen Kondo NP Address 103 Sittdrly Road,Clifton Park Town,New York 12065 Death Certificate Filed District Number Register Number City,Town or Village South Glens Falls Village 4524 20 ❑Burial Date Cemetery,Crematory or Facility Name 10/06/2021 Pine View Crematory nEntombment Address nCremation Queensbury Town,New York nDonation ZZ ❑Removal Date Place Removed and/or and/or Held F- Hold Address U) 0 Cl) ❑Transportation Date Point of p by Common Shipment Carrier Destination Date Cemetery Address ❑Disinterment ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls, New York 12803 Name of Funeral Firm Making Disposition or to Whom i— Remains are Shipped,If Other than Above Address CC W 0- Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/06/2021 Registrar of Vital Statistics Joy Bartholomew(6(ectronica((y Signed) (signature) District Number 4524 Place South Glens Falls Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ~ W4 J/ 7,itr Date of Disposition /D1i,� Place of Disposition tat �,�. 2 (address) W CC N (section) n (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises 1 f.+ �Iwnbt'f if (plea print) W Signature Title `Y' 'rf 71V DOH-1555(07/18)p 1 of 2 I Public Health Law Sec. 4145(2b) 1 Receipt Human remains of t ' delivered on - ' ' , 20 -1 Pine View Cemetery Representing the funeral home named,Y burial permit Official Funeral Directors Reg.or License# '-` "'