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Chenier, Kelly A. AMA NEW YORKSTATE DEPARTMENT OF HEALTH s '• Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Kelly A.Chenier Female Date of Death Age If Veteran of U.S.Armed Forces, 10/05/2020 63 Years War or Dates p. Place of Death Hospital,Institution or Z City,Town or Village Warrensburg Town Street Address 122 Jenni Jill Drive,Warrensburg Town, New York 12885 Manner of Death © 1=1 Undetermined Pending Cause Accident Homicide Suicide W Circumstances Investigation W Medical Certifier Name Title CI Frances Bollinger MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Warrensburg 5660 23 ❑Burial Date Cemetery,Crematory or Facility Name 10/08/2020 Pine View Crematory Entombment Address X❑Cremation Queensbury Town,New York ElDonation o ElRemoval Date Place Removed and/or and/or Held - Hold Address 0 0- Date Point of Cl) ❑Transportation by Common Shipment Carrier Destination El 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 t— Remains are Shipped,If Other than Above " Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/07/2020 Registrar of Vital Statistics Tame&a 9l2 LCoyd(ECectronicaCCy Signed) (signature) District Number 5660 Place Warrensburg, 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 (OI$PO Place of Disposition 'atU t-- 'on__ 2 (address) W CC (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premise6 ht �,^�I ff Z Alease print) W Signature Title f rPli it DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 01 4 0 8 3 Receipt Human remains of delivered on , 20 f ` Pine View Cemetery Representing the iuneral home named on burial permit Official Funeral Directors Reg.or License#