Dennis, Peter '-q
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Peter Dennis Male
Date of Death Age If Veteran of U.S. Armed Forces,
3/17/2020 18 weeks War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death FX—]Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Glens Falls Hospital
Address
Glens Falls
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601
❑Burial Date Cemetery or Crematory
❑Entombment March 20,2020 Pine View Crematorium
Address
®Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
ZC ❑Removal and/or Held
and/or Address
Hold
N
O Date Point of
IL
N ❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑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
Permission is hereby granted to dispose of the human remains de cribed a ve s dicated.
Date Issued Oj 201&2-4� Registrar of Vital Statistics .
(signature)
District Number Place , �Vx;
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 2/ Place of Disposition ?+,,)e O'e-y
2 (addres
W
N
a' (section) / (lot num er) (grave number)
pName of Sexton or Person in Charge of Premises
Z (please print)
W
Signature Title !gL4
(over)
DOH-1555(02/2004)
Public Health Law Sec. 4145(2b) 013 4` 4-
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#