Peltz, Ernest Graham NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Ernest Graham Peltz Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/01/2020 93 Years Waror Dates 43-46
F. Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 71 Longview Drive,Apt 171,Queensbury Town,New York 12804
p Mannerof Death 91 Natural Cause Accident Homicide Suicide Undetermined Pending
U Circumstances Investigation
GMedical Certifier Name Title
Mary Stein NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 1
Burial Date Cemetery,Crematory or Facility Name
01/02/2020 Pine View Crematory
Entombment Address
Cremation Queensbury,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
H N Hold Address
O
4. Date Point of
N ❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
�— Remains are Shipped,If Other than Above
g Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/02/2020 Registrar of Vital Statistics Carm'=e-W.-fdegarde Bar6er(E&tronicaf Soe4
(signature/
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H .
W
Z Date of Disposition ) J 3 ?o Place of Disposition /f�dov�,
2 (address/
W
Q (section/ (lot number/ (grave number)
aName of Sexton or Person in Charge of Premises :y L
� lease P rint)
W Signature //' ✓l l' Title f fl*"
DOH-1555(07/18)p 1 of 2
s
Public Health Law Sec. 4145(2b) 013195
5
Receipt
-- t
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#