Cook, Cheney il # ( c11
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
. Name First Middle Last Sex
Cheney O. Cook Male
:i Date of Death Age If Veteran of U.S. Armed Forces,
November 5, 2014 92 War or Dates World War II
•
rs Place of Death Hospital, Institution or
City, Town or Village Ft. Edward Street Address Fort Hudson Nursing Home
Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Daniel Larson
g Address
; .; 9 Carey Road,Queeensbury,NY 12804
Death Certificate Filed District Number Register,Number
City, Town or Village Fort Edward 5755 '].3
,57..7. ❑Burial Date Cemetery or Crematory
CI Entombment November 6, 2014 Pine View Crematory
Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F' Hold
Cl)
0 Date Point of
y I I Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
: Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
:; Permission is ereby granted to dispose of the human rains described a ove a indicated.
Date Issued I Registrar of Vital Statistics illi t G M "
V (signature)
::::3 District Number 5755 Place Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
uiDate of Disposition !1/71/y Place of Disposition .ot,U... ,r,,,., $`,
W (address)
N
0 (section) number) (grave number)
0p Name of Sexton or Person in Charge of Premises d:.,1lot
3 rink+
Z // ( ease print)
W Signature L/ Title (YV1cu .
(over)
DOH-1555(02/2004)