Chenier, Theresa NEW YORK STATE DEPARTMENT OF HEALTH ' 'f '� '2_ 4 1 12-
Vital Records Section Burial - Transit rermit
Name First Middle Last Sex
Theresa Daley Chenier Female
� Date of Death Age If Veteran of U.S. Armed Forces,
February 22, 2012 83 War or Dates
ZPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
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• Manner of Death 4 Natural Cause Accident Homicide Suicide Undetermined Pending
UJ Circumstances Investigation
U Medical Certifier Name Title
14,' Mark Hoffman MD
Address
a 100 Park Street Glens Falls, NY 12801
Death Certificate Filed Glens Falls District Number Register Number
City, Town or Village 5601 73
❑Burial Date Cemetery or Crematory
March 1, 2012 Pine View Crematorium
Entombment Address
❑x Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address
F' Hold
N
O Date Point of
(0 Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date ' Cemetery Address
1
Permit Issued to Registration dumber
: 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
f+ Remains are Shipped, If Other than Above
Address
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us
Permission is hereby ranted to dispose of the human remains escribed a ove as indi ated
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Date Issued • Registrar of Vital Statistics a , .
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above wer disposed of in accordance with this permit on:
W £e Date of Disposition D iti 7p,Z RA)
Place of Disposition Ctt+ticlel1�..
5 % (address)
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CO
IZ (section) - (lot number) (grave number)
O Name of Sexton or Per on in Charge o remises t�.lft
ZI /1r,34,f/40-- (please print)
W Signature -itt Title CEPS++6-Vt.
U (over)
DOH-1555(02/2004)