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Chapin, Richard Alan ll ©IF Ajt--) NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Richard Alan Chapin II Male Date of Death Age If Veteran of U.S.Armed Forces, 03/15/2023 38 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Moreau Town Street Address 1611 Saratoga Road, Moreau Town, New York 12803 W p Manner of Death []Natural Cause []Accident []Homicide []Suicide []Undetermined []Pending U I 1 I (Circumstances I 'Investigation LU Medical Certifier Name Title CI Anthony Perniciaro Coroner Address 6012 County Farm Road,Ballston Spa Village,New"ork 12020 Death Certificate Filed Town Of Moreau District Number Register Number City,Town or Village 4562 15 []Burial Date Cemetery,Crematory or Facility Name 03/20/2023 Pine View Crematorium []Entombment Address ©Cremation Queensbury Town,New York IIIDonation ZZ 0❑Removal Date Place Removed and/or and/or Held N Hold Address 0 d Date Point of (A Transportation by Common Shipment Carrier Destination O Disinterment Date Cemetery Address Date Cemetery Address E Reinterment 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 Remains are Shipped,If Other than Above Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/20/2023 Registrar of Vital Statistics Brenda Nutter(E(ectronicaCCy Signed) (signature) District Number 4562 Place Town Of Moreau I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H Z Date of Disposition ,I2f)73 Place of Disposition .f— r, >� 2 /address W N (section) 1 (lot number) (grave number) oName of Sexton or Person in Charge of Premi A n' �f Z lease prin W Signature Title ({ li'ntoe DOH-1555(07/18)p 1 of 2 k l ..6 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# `+