Chesney, Kathleen NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
g;' Name First Middle Last Sex
Kathleen Chesney Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 21, 2012 72 War or Dates No
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
a, Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
U.t Circumstances Investigation
w Medical Certifier Name Title
Mary C.Kilayko Dr.
Address
n 100 Park St.,Glens Falls,NY 12801
1-•: Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 8.g
❑X Burial Date Cemetery or Crematory
February 27,2012 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date 1 Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
:F Permit Issued to Registration Number
:: Name of Funeral Home Regan& Denny Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
': Name of Funeral Firm Making Disposition or to Whom
ii4 Remains are Shipped, If Other than Above
:t Address
:>
Permission is hereby granted to dispose of the human remains d scribed ab ve as indic ed.
Date Issued Registrar of Vital Statistics -7-i4-G . ,C a92--e
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 2/27/1 2 Place of Disposition Pine View Cemetery
2 (address)
LO W Hudson Sec. 1 8B 3
rd (section) (lot number) (grave number)
QName of Sexton or Perso in Charge of Premises Michael Genier
Z .. (please print)
W
Signature v Title Superintendent
(over)
DOH-1555(02/2004)