Chapman, Michael John * . ''''''4 c„, ?/ /-0).3
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Michael John Chapman Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/13/2023 65 Years War or Dates 1976-1980
' Place of Death Hospital,Institution or
2 City,Town or Village South Glens Falls Village Street Address 62 Harrison Avenue,South Glens Falls Village,New York 12803
IU
O Manner of Death X❑Natural Cause Accident 0 Homicide OSuicide Undetermined Pending
11.1
Circumstances Investigation
1• Medical Certifier Name Title
O Kathleen Huestis MD
Address
101 Ridge,Glens Falls,New York 12801
DeaBth Certificate Filed Village Of South Glens Falls District Number Register Number
City,Town or Village 4524 21
Burial Date Cemetery,Crematory or Facility Name
12/15/2023 I Pine View Crematory
Entombment Address
1
®Cremation Queensbury Town,New York
Donation
ZRemoval Date Place Removed
and/or and/or Held
- Hold Address
CO
0
a Date Point of
CO ETransportation
0by Common Shipment
Carrier Destination
Disinterment ID
Date Cemetery Address
Date Cemetery Address
E Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
b Remains are Shipped,If Other than Above
2 Address
CC
Q. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/15/2023 Registrar of Vital Statistics Samantha Berg gkctrunrcallySigned)
(signature)
District Number 4524 Place Village Of South Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition /2 / '/6-Zez3 Place of Disposition ,'U (�C Lip. 1-C7y/A
ILI
2 (address)
W
Cr (section) (l number) (grave number)
8 Name of Sexton or Person in Charge of P ise r lS/✓9f'//''lc"t 6 WOcei
Z (please print)
W Signature I ` Title eye'<v
DOH-1555(01/18)p 1 of 2 G'
1 7 62
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#