Chenier, Madeline NEW YORK STATE DEPARTMENT OF HEALTH s # 2 7
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Madeline Elizabeth Chenier , Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 24, 2011 93 War or Dates
ZZPlace of Death Hospital, Institution or
City, Town or Village Argyle j Street Address Pleasant Valley Nursing Facility
0 Manner of Death ZJ Natural Cause (�Accident ]Homicide ❑Suicide Undetermined ❑Pending
�" Circumstances Investigation
w Medical Certifier Name Title
13 Address f
�C 4/- , /� 3 `l
Death Certificate Filed District Number Register Number
City, Town or Village Argyle ! 3 N7) 3
❑Burial Date Cemetery or Crematory
❑Entombment May 28,2011 Pine View Crematorium
Address
1i Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
I,:: Hold
co
0 Date Point of
5 ❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
� I
Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Funeral Home 01464
• Address
• 53 Quaker Road,Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
M Remains are Shipped, If Other than Above
g Address
Ce
US
CL
Permission is hereby granted to dispose of the huma mains described ove as indicated.
Date Issued,*S// I Registrar of Vital Statistics
• - 1P (signature)
District Number Place 7 —x eV " c v J
I certify that the remains of the decedent identified above were dis osed of in acco ance with this permit on:
Z d �W Date of Disposition ,$�11��� Place of Disposition 1,y tw c rk,,,"
W (address)
CO
OC (section) 4ik
(lot nu er) (grave number)
pName of Sexton or P son in Charge Premises t
2 (please print)
W
Signature Title ll:N E
(over)
DOH-1555(02/2004)