Chenier, William NEW YORK SATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
William Francis Chenier Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 9, 2012 40 War or Dates
Place of Death Hospital, Institution or
' , City, Town or Village Street Address Glens Falls Hospital
to Manner of Death M Natural Cause Accident Homicide Suicide Undetermined Pending
%� Circumstances Investigation
to M• edical Certifier Name Title
PI' Graham Atkins MD
Address
Glens Falls,NY
Death Certificate Filed I District Number Register Number
ry City, Town or Village Glens Falls 5601 5 1j 3
❑X Burial Date Cemetery or Crematory
Entombment Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, , NY 12804
Date Place Removed
Z Removal i and/or Held
and/or Address
F' Hold
Cl)
O Date Point of
N Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
1
P• ermit Issued to Registration Number
s Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
3 407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
l Remains are Shipped, If Other than Above
N Address
tL
tit
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued l 2) 1 0`1 Z Registrar of Vital Statistics i/o cM�,.� W
(signatu )
D• istrict Number 5601 Place Glens Falls hit j
I• certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 1 2/1 2/1 2 Place of Disposition Pine View Cemetery
W (address)
tI) Erie 82 C 2
CL (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises Michael Genier
Z (please print)
W SignatureC)(N•f.:(.14..t.Q 915,./v‘A-2,‘,'
Title Superintendent
(over)
DOH-1555(02/2004)