Duell, Peter NEW YORK STATE DEPARTMENT OF HEALTH
Vitaeecords Section Burial - Transit Permit
Name First tM dle `Last S
r*i91-tr
...... p,--,--„,y,
<<= Date of Death / . Age eran of U.S.Armed Forces
/ / 3/ /Z_ (/3 or Dates �� ,(
-ce of Death Hospital titution or/)
10 Town or Village CU6-,.,s ha'w S eet Address LI f,E'er-c y J
annex of DeathXNatural Cause 0 Accident n Homicide Q Suicide �Undetermined Q Pending
- Circumstances Investigation
La Medical Certifier Name Title }
02 Q � ,,d / C - i i 1 /f
Address /°2- Pel.U4-. c C ! C3�41' r,Y 12
th Certificate Filed District Number j Regis r Nurpbeer
Ci , own or Village ((,,(ems...)S `-C- 5 `6 0 t--t
1.11 urial Date / C Cemete or Crematory,- /
igi Entombment Address /�/ CM
I OCremation /,�h AJ 7-- @ 0 -t,'rJLC Q L k/
Date Place Removed �
Removal and/or Held
and/or Address
Hold
III
10. Date Point of
Transportation Shipment
by Common Destination
!!!0i. Carrier
Date Cemetery Address
'z El Disinterment
Reinterment Date Cemetery Address
IiR Permit Issued to Registration Number
Name of Funeral Home VAGytnai ct b, €Sol er Funex GL) '` tsreig_ 01 i 30
MI Address
Name of Funeral Firm Making Disposition or to Whom
bw Remains are Shipped, If Other than Above
IAddress
Permission is hereby granted to dispose of the human remains described above as indicated.
gi Date Issued )131 ( 2 Registrar of Vital Statistics j ) LA)CJ"—U " (signature)
Ar District Number 6-6 O/ Place G -S \ ) /1t V
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
la Date of Disposition 2/7/1 2 Place of Disposition West Glens Falls Ce mP e-r y
(address)
- tI
Family Plot
it (section) (lot number) (grave number)
Name of Sexton or Perso Charge of Premises Mi r}i L Genier
i
(please print)
14)3,:i:i: Signature _ "' Title Superintendent
(over)
DOH-1555 (02/2004)