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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Marcus Merton Chapman Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/07/2024 53 Years War or Dates
F Place of Death Hospital,Institution or
Z City,Town or Village Hartford Town Street Address 7180 State Route 40, Hartford Town, New York 12809
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Manner of Death Natural Cause [] ❑
Accident Homicide Suicide ❑Undetermined Pending
I I Circumstances Investigation
W Medical Certifier Name Title
0 Lauren Dinsmore PA
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Hartford District Number Register Number
City,Town or Village 5759 13
H
Burial Date Cemetery,Crematory or Facility Name
02/09/2024 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
F- Hold Address
N
0
G. Date Point of
(/)❑Transportation
p by Common Shipment
Carrier Destination
o
Disinterment
Date Cemetery Address
Date Cemetery Address
E Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
g Address
CC
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/08/2024 Registrar of Vital Statistics rDenire Petteys(ETectronicaf Signed)
(signature)
District Number 5759 Place Town Of Hartford
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
II—
I Date of Disposition _%'-2,2�7i. Rive, �Place of Disposition nfe, e� C,A irtrij ft_
2 (address)
W
NCC (section) (11 number) (grave number)
0 Name of Sexton or Person in Charge of emises / )�it'hli.4 (� 1 a
Z ��� / (please print)
W g , �G� Title 0e-�<c4 04
Signature � �.�>E/2�
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
1
1
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#