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Cheney, Arthur Fay Zed NEW YORK STATE DEPARTMENT OF HEALTH 0 Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Arthur Fay Cheney Male Date of Death Age If Veteran of U.S.Armed Forces, 01/08/2022 86 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Fort Edward Town Street Address 254 Woodard Road, Fort Edward Town,New York 12828 p Manner of Death ©Natural Cause ❑Accident Homicide El Suicide DUndetermined ❑Pending uJ Circumstances Investigation 0 WI Medical Certifier Name Title Curtis Gedney MD Address 454 Glen Street,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 3 Burial Date Cemetery,Crematory or Facility Name 01/11/2022 Pine View Crematory Entombment - Address X❑Cremation Queensbury Town,New York ▪Donation ZZ Removal Date Place Removed and/or and/or Held N Hold Address 0 d Date Point of Cl) ❑Transportation p by Common Shipment Carrier Destination El Disinterment Date Cemetery Address EReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079 Address 82 Broadway,Fort Edward,New York 12828 Name of Funeral Firm Making Disposition or to Whom F— Remains are Shipped,If Other than Above a Address W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/11/2022 Registrar of Vital Statistics Aimee L Mahoney(ECectronica1Ty Signed) (signature) District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: t;uV.. 9 Z Date of Disposition 1/li l Z2 Place of Disposition . . 440 UJ 2 (address) W CC (section/ Ala number) (grave number) ,QM O' Name of Sexton or Person in Charge f Premises Kit— (please t/ /` W Signature Title l WMat- DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#