Moger, Chapin F NEW YORK STATE DEPARTMENT OF HEALTH 322
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Chapin F Moger Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/11/2022 85 Years War or Dates 1960-1962
i— Place of Death Hospital,Institution or
W City,Town or Village Queensbury Town Street Address 8 Highpointe Drive,Queensbury Town,New York 12804
pManner of Death ❑x Natural Cause Accident ❑Homicide Suicide Undetermined Pending
U Circumstances Investigation
W Medical Certifier Name Title
G Charles Yun MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 73
Burial Date Cemetery,Crematory or Facility Name
04/15/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
DDonation
ZO❑Removal Date Place Removed
and/or and/or Held
H Hold Address
CO
0
11. Date Point of
(A Transportation Shipment
p by Common
Carrier Destination
Disinterment
Date Cemetery Address
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
i— 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 04/15/2022 Registrar of Vital Statistics Caroline JhhC1egarde Barber('Electronically Signed)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
▪ Date of Disposition :'J-K..Zc)22 Place of Disposition 7i-vte-11r -.c) -1ev7-2-4.< r0/�f
2 (address) /
W
NCC (section) (lot number) (grave number)
O Name of Sexton or Person i harge of Premises --1.., �'�-✓t �G' G v�`�
Z (please print)
W Signature Title Grern4 k,, ye,- ,�-/
DOH-1555(07/18)p 1 of
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#