Chlopecki, Claudia M .0
N EW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Claudia M.Chlopecki Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/12/2022 84 Years War or Dates
F . Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
Ill
0 Manner of Death []Natural Cause []Accident ❑Homicide [] [] ❑
Suicide Undetermined Pending
✓ I i 'Circumstances Investigation
W Medical Certifier Name Title
O Kasandra Frasier PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 621
Burial Date Cemetery,Crematory or Facility Name
12/13/2022 Pine View Crematory
Entombment Address `""""
Cremation Queensbury Town,New York
Donation
Z Removal Date Place Removed
and/or and/or Held
1— Hold Address
N
0
d Date Point of
U)❑Transportation
G by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Date Cemetery Address
❑Reinterment
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1.. Remains are Shipped,If Other than Above
Address
Q
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/13/2022 Registrar of Vital Statistics Megan r`trorn(fE/ctronicall:y Signed)
(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:
IF—
Z � _
tu
Date of Disposition 17I M i n Place of Disposition 1 4 IL_2 t (address)
W
N (section) (lot number) (grave number)
G0 4t
Name of Sexton or Person in Charge Premises A
Z (pie e print) /
W Title t riAtil re—
Signature
DOH-1555(o7/i8)p 1 of 2
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#