Avery, Peter _565
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Peter J. Avery Male
l Date of Death Age If Veteran of U.S. Armed Forces,
07 / 23 / 2017 70 War or Dates N/A
}- Place of Death Hospital, Institution or
ZCity, Town or Village Saratoga Springs Street Address Saratoga Hospital
ct Manner of Death El NaturalCause E Accident 0 Homicide E Suicide �Undetermined 0 Pending
Circumstances Investigation
0.
la Medical Certifier Name Title
Theodoros Laddis MD
Address
6 Medical Park Dr. Suite 205, Malta, NY 12020
• Death Certificate Filed District Number Register Number
City, Town or Village Saratoga springs Lq 5 6' e'5ts/7-
i!!:!!;iii OBurial Date Cemetery or Crematory
07 / 24 / 2017 Pine View Crematory
aiii0Entombment Address
gi Cremation Queensbury, NY
Date Place Removed
X g 7❑Removal and/or Held
and/or Address
L
Hold
Date Point of
0 Transportation Shipment
by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
ni Address
402 Maple Ave. , Saratoga Sp., NY 12866
: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
fr
Ili
Permission is he by gr nted to dispose of the human remai ri d atop 'ndicate
Date Issued ""') 7 i ) Registrar of Vital Statistics
(signature)
District Number 1 $ D I Place Saratoga Springs , New York
#r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ta / era y
Date of Disposition � 2 S-f7 Place of Disposition oYJ�t/r /'
II (address)
tii
fa
l (section) ` (lot n ber) (grave number)
IIName of Sexton or P h ge of Premises `�.L//a /. G Ca
2 (please print)
la
Signature Title C.O 41✓cv,--
(over)
DOH-1555 (02/2004)