Cherney, Hans NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
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f`s Name First Middle Last Sex
Hans Chanan Cherney Male
Date of Death Age If Veteran of U.S. Armed Forces,
>.> May 27,2015 93 War or Dates n/a
.'' Place of Death Hospital, Institution or
City, Town or Village Queensbury, NY Street Address 39 Longview Drive, Apt 136
Manner of Death a Natural Cause Accident I Homicide I Suicide ❑Undetermined 1-7 Pending
Circumstances Investigation
Medical Certifier Name Title
Michael Fuller,MD
Address
''' 48 East Street,Fort Edward,NY 1282
Death Certificate Filed District Number Regjsi Number
><.';` City, Town or Village Queensbury,NY 5657 ((//��
❑Burial Date Cemetery or Crematory
❑Entombment May 29, 2015 Pine View Crematorium
Address
1I Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z ❑Removal and/or Held
O
and/or Address
H Hold
N
O Date Point of
u) ❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
f ' Permit Issued to Registration Number
'>' Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
%`�/ 407 Bay Road,Queensbury,NY 12804
fl Name of Funeral Firm Making Disposition or to Whom
I:: Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re ains e crt6edgv a ' dicated.
Date Issued S ` ,"1-15 Registrar of Vital Statistics v 0 c CL
j
(signature
f District Number 5 LS1 Place t z)i.A . c k.ri._e.A A L.,
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I certify that the remains of the decedent identified abov were disposed of in a Gordan with this permit on:
uiDate of Disposition b I I I lc Place of Disposition KJ, ,�
W (address)
(I)
OC (section) A (lotnumber) (grave number)
Op Name of Sexton or Person in Charge of Premises i4.:. Sc.•wq-
Z (ple se print)
W Signatures Title filfrotfl
(over)
DOH-1555(02/2004)