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Cherniske, Joseph • _ T (c0t5 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section 4 • Burial - Transit Permit Name First Middle Last Sex Joseph S. _ Cherniske Male Date of Death Age If Veteran of U.S. Armed Forces, December 11, 2011 1 66 War or Dates No H Place of Death Hospital, Institution or Z City, Town or Village Queensbury Street Address 12 North Ct. pManner of Death I XI Natural Cause I I Accident Homicide Suicide Undetermined Pending W Circumstances Investigation tww Medical Certifier Name Title CI_ John Sawyer DR. Address 14 Manor Drive,Queensbury,NY 12804 Death Certificate Filed District Number ' Register Number City, Town or Village Queensbury 5657 3 d ❑Burial j Date Cemetery or Crematory December 13, 2011 Pine View Crematorium ❑Entombment Address X Cremation Quaker Road, Queensbury, NY 12804 Date Place Removed ZZ I I Removal and/or Held and/or Address H Hold U) 0 Date Point of NTransportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date ' Cemetery Address Permit Issued to I 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 i-- Remains are Shipped, If Other than Above 2 Address re W_ CL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 1,-),\ 13( ©k1 Registrar of Vital Statistics �c,_ `_5<S (signature) District Number 5657 Place Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition Pt( 14 IDAA Place of Disposition ,,VA-) Cruh4cx'i&, 2 t (address) W CO rt (section) (lot number) (grave number) pName of Sexton or Person in Charge of Pre ises e t.141‘704r.. iNrtlk ZAL (please print) W Signature Title Cist i o(l (over) DOH-1555(02/2004)