Cheeney, Peter D r , F \ ,ki `�
�
NEW YORK STATE DEPARTMENT OF HEALTH \
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
PETER D. CHEENEY Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 24,2022 73 War or Dates 02/01/1967 01/28/1971
F-+ Place of Death VAMC ALBANY NEW YORK Hospital, Institution or
csiZ City, Town or Village Street Address 113 HOLLAND AVE,
Manner of Deathryi Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
DR. MUHAMMAD J. JAVED M.D.
1, Address
"° Death Certificate Filed ,D / District Number Register Ny er
City, Town or Village !'/ //,Of G1 1/ 0 &
�
"
Date Ce etery or Crem.tdry�
: ❑Burial ,,_ 261 -ZZ
�N-. V\e CS.'x.amcAtp-
■Entombmentwar Address
al:Cremation lCir_ pl(R C.)A QUZ_eX`fJ ) ;\\3\
Date Place Removed
❑Removal and/or Held
..,. and/or Address
Hold
Date Point of
ftEl Transportation Shipment
i by Common Destination
Carrier
Disinterment Date Cemetery Address
El
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M Oe tt,Fitz (�u a (.�rD� 0 I U.)
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued November 24,2022 Registrar of Vital Statistics .J'a, t' S /-,.4/40 f 0n
(signaatture)
District Number lc Place VAMC ALBANY 113 HOLLAND AVE,ALBANY NEW`FORK 12208
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
la Date of Disposition 17 1, 1 Zt Place of Disposition -`-V-- /. Dry---_
a (address)
01
te Name of Sexton or Person in arge of (section) /?.1‘
(lot.nummber) s ti(grave number)
Prem. '
lea )ILl Signature p Title �f' 4Nk
(over)
DOH-1555 (02/2004)
€ 3 y ". n 2
,.
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
i
Pine View Cemetery Representing the funeral home named,on burial.permit
Official Funeral Directors Reg.or License#