Rapp, Carol A ',,,Q...F.'), ii 5
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records -- Burial -Transit Permit
Name First Middle Last ' Sex
Carol A.Rapp
Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/14/2022 76 Years War or Dates
Place of Death Hospital,Institution or
Z
City,Town or Village Chester Town Warren Street Address 7 Panther Mountain Road 1,Chester Town Warren,New York 12817
w Manner of Death Undetermined Pending
� �NaturalCause ❑Accident Homicide Suicide
W Circumstances Investigation
0
W Medical Certifier Name Title
0 John Stoutenburg MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Or Chester District Number Register Number
City,Town or Village 5652 6
Burial Date Cemetery,Crematory or Facility Name
04/16/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
DDonation
KilRemoval Date Place Removed
and/or and/or Held
F- Hold Address
CO
0
O. Date Point of
CA[Transportation Shipment
p by Common
Carrier Destination
❑Disinterment
Date Cemetery Address
Date Cemetery Address
Rei me rment
Permit Issued to Registration Number
Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141
Address
9 Pine St,Chestertown,New York 12817
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
Q
W
0' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/16/2022 Registrar of Vital Statistics ttf 3'Conway'(Eitromca4J'ss1n eOJ
(signature)
District Number 5652 Place Town Of Chester
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 41//i-ZBZL Place of Disposition tJC- U'i e„4) i Chefri -fo 4.-
ui
2 address,
W
Cl) (section) / (lot n ben) (grave number)
G Name of Sexton or Person in Cha of Premi inVi✓).- a7 . ilooA
z
(Please print)
W Signature '''5 Title 0 -P�`4'
DOH 1555(07/18)p 1 of 2
•
.; 5 9.74
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# � ._