Greenholtz, Cheryl s
t.
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Cheryl D Greenholtz Female
501 Date of Death Age If Veteran of U.S. Armed Forces,
iiP 12/15/2018 69 years War or Dates
Place of Death Hospital, Institution or
uiz City,A4030 = OW Glens Falls Street Address Glens Falls Hospital
0 Manner of Deathr,❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
in Circumstances Investigation
L Medical Certifier Name Title
Pit Bryan Smead M D
Address
Warrensburg Health Center, Warrensburg, N Y
Death Certificate Filed District Number Register Number
iM City,XIXXX XO( Xje Glens Falls 5601 590
❑Burial Date Cemetery or Crematory
❑Entombment 01/11/2019 Pineview Cemetery
Address
'<['Cremation Queensbury, N Y
iiiDate Place Removed
Z❑Removal and/or Held
Orr and/or Address
C Hold
CO
O Date Point of
co❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral HomeAlexander- Baker Funeral Home 00037
Address
pi 3809 Main Street Warrensburg, N Y 12885
Name of Funeral Firm Making Disposition or to Whom
I„- Remains are Shipped, If Other than Above
2 Address
it
w
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/18/2018 Registrar of Vital Statistics LA)c&
(s nature)
Ili District Numbe5601 Place Glens Falls) iv
' '
f' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
tLI Date of Disposition 1 /1 1 /201 9 Place of Disposition Pine View Cemetery Queensbury
2 (address)
LEA
CO Erie 76-F 2
IX (section) (lot number) (grave number)
• Name of Se ton or Person in Charge of Premises Connie L. Goedert
2 (please print)
• Signatur !� Title Cemetery Superintendent
(over)
DOH-1555 (02/2004)