Chambers, Matthew Jay ' nt5 ) it 13
NEW YORK STATE DEPARTMENT OF HEALTH
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Matthew Jay Chambers Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/20/2022 67 Years War or Dates 1974-1978
Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address 21 Hartford Avenue Apt A,Glens Falls,New York 12801
p Manner of Death ❑X Natural Cause ❑Accident I:IHomicide Suicide FlUndetermined ri Pending
W Circumstances Investigation
W Medical Certifier Name Title
CI Timothy Murphy Coroner
Address
52 Haviland Avenue,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
,Town or Village Cie 5601 590
Burial Date Cemetery,Crematory or Facility Name
11/28/2022 Pine View Crematorium
Entombment Address
EjCremation Queensbury Town,New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
NHold Address
0
0. Date Point of
U)ElTransportation Shipment
$ by Common
Carrier Destination
Date Cemetery Address
Disinterment
El Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
lr Remains are Shipped,If Other than Above
S Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/28/2022 Registrar of Vital Statistics Megan No(in(ECectronica1ySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z li —
W Date of Disposition f f 179 1 22 Place of Disposition �,�
2 (address)
W
N (section) (lot number) (grave number)
CC
8 Name of Sexton or Person in Charge o emises n' 0
Z (pleaa print)
W Signature l� Title `*MO rOte
DOH-1555(07/18)p i of 2
.. oJ1643
1 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# / a .