Peake, Phyllis III
NEW YORK STATE DEPARTMENT OF EAL [n
Vital Records Section Burial - Transit Permit
M'' Name First Middle Last Sex
- ' Phyllis H. Peake Female
Date of Death Age - If Veteran of U.S. Armed Forces,
_', 12/12/2018 86 War or Dates
4
; Place of Death Hospital, Institution or
' City, Town or Village Queensbury Street Address 12 Gentry Lane
Manner of Death ❑X Natural Cause ❑Accident ❑Homicide ❑Suicide 1-1 Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
EE, Address
SwF
tr,t Death Certificate Filed District Number Register Number
City, Town or Village Queensbury,New York 5657 j'l
❑Burial Date Cemetery or Crematory
❑Entombment December 14, 2018 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO ❑Removal and/or Held
and/or Address
H Hold
O Date Point of
O ❑Transportation Shipment
p by Common Destination
Carrier
El Disinterment Date _ ry Address
Ell Renterment Date Cemetery Address
Iii
Permit Issued to Registration Number
rr
Nam;, Name of Funeral Home Regan Denny Stafford Funeral Home 01443
40 Address
t 53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human m a a�'�'dicated.
eDate Issued (a,-(�- Q Registrar of ital Statistics Lspc
(si• ature)
• District Number Place b li/lk. , 1/,IA LI
- .Lt' I certify that the remains of the decedent identified abo t were disposed of in acc anc with this permit on:
iti Date of Disposition 12411 h4 Place of Disposition p t-f !. i or1
W (address)
U)
C4 (section) number) (grave number)
Q Name of Sexton or Person in Charge of Premises (rot
..}}ppkd- S tv004
Z (pte'ak print)
W Signature 79 .1(-
Title friritiq it&.
(over)
DOH-1555(02/2004)