Pettersen, Edwin NEW `CORK" ATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
r,:< Name First Middle Last Sex
%% Edwin A. : pettersen Male
'`f%' Date of Death Age If Veteran of U.S. Armed Forces,
�>> April 24, 2013 93 War or Dates
F Place of Death Hospital, Institution or
'Z City, Town or Village Queensbury Street Address 39 Longview Drive
Manner of Death Undetermined Pending
X Natural Cause Accident �Homicide n Suicide n �
Circumstances Investigation
Medical Certifier Name Title
Philip J. Gara,MD
Address
Broadway,Ft.Edward,NY 12828
' Death Certificate Filed District Number Register Number
h City, Town or Village Queensbury Queensbury £ S
ED Burial Date Cemetery or Crematory
❑Entombment April 27,2013 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, , NY 12804
Date Place Removed
Z 0 Removal and/or Held
0 and/or Address
f" Hold
U)
0 Date Point of
y f]Transportation Shipment
a by Common Destination
Carrier
Date Cemetery Address
I ,Disinterment
Li Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address —
t ..
Permission is hereby granted to dispose of the human reins described above-as indicated.
r Date Issued ''-, - 13 Registrar of Vital Statistics 6J its
(signature)
District Number Queensbury Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Pine View Cemetery� Date of Disposition 4/2 7/1 3 Place of Disposition
Ai (address)
(I) Erie 35G 4
0 (section) (lot number) (grave number)
Z Name of S n or Person in Charge of Premises Connie . Goedert
g kit-Q.
i (please print)
W v�o`
Si natur Tit
(over)
DOH-1555(02/2004)