Pena, George -� ZZL
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
George Pena Male
Date of Death Age If Veteran of U.S. Armed Forces,
03 / 10 / 2020 66 War or Dates N/A
Place of Death Hospital, Institution or
City, Town or Village Milton Street Address 8 Van Tassel Lane
Q Manner of Death Natural Cause ❑Accident Homicide Suicide ❑Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
John Mongan DO
Address
3 Care Ln #300, Saratoga Springs, NY 12866
Death Certificate Filed District Number 6 Register Number
City, Town or Village Milton
< ' Burial Date Cemetery or Crematory
03 / 12 / 2020 Pine View Crematory
Entombment Address
Cremation Queensbury, NY
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
Q Transportation Shipment
470 by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
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
Permission is hereby granted to dispose of the human re ns descri ed a ove as indicated.
Date Issued 3 t� lxrz o Registrar of Vital Statistics
(signature)
District Number b Place Milton , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W. Date of Disposition Place of Disposition
(address)
(section) (lot number) (grave number)
Name of Sexton or Person ip Cha ge of Pr ises �`i L
(ple se punt)
tu
Signature Title '*
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) 13 4 9.1
Receipt
Human remains of delivered on , 20
Pj'e View Cemetery Representing the funeral home named on burial permit
%Official Funeral Directors Reg.or License#