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Chenier, David J
41 If NEW YORK STATE DEPARTMENT OF HEALTH -�. Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex David J.Chenier Male Date of Death Age If Veteran of U.S.Armed Forces, 08/12/2023 32 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Indian Lake Town Street Address 146 Big Brook Road, Indian Lake Town, New York 12812 p Manner of Death Natural Cause Accident ❑X Homicide Suicide nUndetermined Pending 0 W 1 ('Circumstances Investigation WW Medical Certifier Name Title 0 Matthew Miller Coroner Address P.O.Box 250, Indian Lake,New York 12842 Death Certificate Filed Town Of Indian Lake District Number Register Number City,Town or Village 2053 8 Burial Date Cemetery,Crematory or Facility Name 08/16/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town, New York Donation ZZ❑Removal Date Place Removed and/or and/or Held - Hold Address 0 n. Date Point of U) Transportation by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Miller Funeral Home 01199 Address 6357 Nys Rte#30, Indian Lake, New York 12842 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 2 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/15/2023 Registrar of Vital Statistics Julie A Clawson(Electronically Signed) (signature) District Number 2053 Place Town Of Indian Lake I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H Z Date of Disposition 8 1 1-)I Z3 Place of Disposition W (address) W f/) (section) of number) (grave number) 0 Name of Sexton or Person in Charge of Premises Z (p14e print) W Signature C// Title ��A7W(c DOH-1555(07/18)p 1 of 2 .f o, L.. ':' U 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#