Cheung, Ning t F
NEW YORK STATE DEPARTMENT OF HEALTH _
Bureau of Vital Records Burial Transit Permit
Name First Middle Last Sex
Ning Cheung Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/02/2022 59 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W
0
Manner of Death El Natural Cause Accident ❑Homicide lilSuicide Undetermined Pending
✓ Circumstances Investigation
W Medical Certifier Name Title
O Christopher Smith MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 503
HBurial Date Cemetery,Crematory or Facility Name
10/04/2022 Pineview Crematory
Entombment Address
IliCremation Queensbury Town,New York
Donation
Removal Date Place Removed
and/or. and/or Held
F— Hold` Address
N
0
O. Date Point of
Cl)❑Transportation
p by Common Shipment
Carrier Destination
El
Disinterment
Date Cemetery Address
Date Cemetery Address
n Reinterment
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped,If Other than Above
a Address
CC
W
Lt. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/03/2022 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition /0it/In. Place of Disposition 'l r.kv� 4i)r----
2 (address)
W
NCC (section) di' L,
(/ot number) (grave number)
11
0Name of Sexton or Person in Charge remises S ".`
(pi se print)
W Signature Title Crt rd$4 1lc
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#