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Chapman. Sally , . , C....F) fil49— NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Sally Chapman Female Date of Death Age If Veteran of U.S.Armed Forces, 02/06/2024 85 Years War or Dates i_ Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing 11.1 p Manner of Death 0 Natural Cause Accident 11 Homicide Suicide nUndetermined ❑Pending W ' 'Circumstances Investigation C) W Medical Certifier Name Titic CI Jonathan Waldman MD• Address MOW 42 Gurney Lane Lane,Queensbury Town, New York 12804 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 25 Burial Date Cemetery,Crematory or Facility Name 02/08/2024Pine View Crematory Entombment addressdress 111100 ©Cremation Queensbury Town,New York Donation - 0 Removal Date Place Removed and/or and/or Held F- Hold Address CO 0 n- Date Point of t/)nTransportation p by Common Shipment Carrier Destination Date Cemetery Address Disinterment Date Cemetery Address ❑Reinterment Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne, New York 12846 • Name of Funeral Firm Making Disposition or to Whom }. Remains are Shipped,If Other than Above N Address cr W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/08/2024 Registrar of Vital Statistics Caroline Hildegarde 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— � Z Date of Disposition 211101 Place of Disposition 1 7..✓ic J (PE inAiveLi.,_ 2 (address) III CO CC (section) (lot number)Sv, (grave number) 0Name of Sexton or Person in Charge of Premises % t•J\IL 4 liZ �//� lease print) �y W Signature C/ (/ J Title Pe DOH-1555(07/18)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#