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Chenier, Mary Ann
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Mary Ann Chenier Female Date of Death Age If Veteran of U.S.Armed Forces, 05/14/2020 78 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Johnsburg Town Street Address Elderwood at North Creek pManner of Death © Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined EjPending W Circumstances Investigation WMedical Certifier Name Title Kate Sauer-Jones PA Address 112 Ski Bowl Rd,Johnsburg Town,New York 12853 Death Certificate Filed District Number Register Number City,Town or Village North Creek 5655 14 Burial Date Cemetery,Crematory or Facility Name 05/16/2020 Pine View Crematory Entombment Address X❑Cremation Queensbury Town,New York Donation Z Removal Date Place Removed and/or and/or Held �- Hold Address N dDate Point of N Transportation Shipment p by Common Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander Baker Funeral Home 00037 Address 3809 Main St,Warrensburg,New York 12885 Name of Funeral Firm Making Disposition or to Whom E— Remains are Shipped,If Other than Above Address W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/15/2020 Registrar of Vital Statistics Kgtfiken C.Gorah(ECectronicaffy Signed) (signature) District Number 5655 Place North Creek, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: j Z Date of Disposition 57-/-'-2020 Place of Disposition f 'h e V rZ L) LU LU (address) W N (section) of number) (grave number) Name of Sexton or Person in f Premises y` 1� C ` � �` � (please print) W Title Signature DO H-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 013826 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the'funeral home named on burial permit Official Funeral Directors Reg.or License#