Peterson, Debra Ann .•
, 41foo
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Debra Ann Peterson Female
Date of Death Age If Veteran of U.S.Armed Forces,
10/07/2020 57 Years War or Dates
i.. Place of Death Hospital,Institution or
WCity,Town or Village Bolton Town Street Address 42 Rainbow Drive,Bolton Town,New York 12824
0 Manner of Death 0 Natural Cause ❑Accident u Homicide ❑Suicide ❑Undetermined ❑Pending
111
Circumstances Investigation
IJJ Medical Certifier Name Title
0
Laurie Dennison NP
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Bolton Landing 5650 11
0 Burial Date Cemetery,Crematory or Facility Name
10/10/2020 Pine View Crematory
0 Entombment Address
0 Cremation Queensbury,New York
❑Donation
0El
Removal Date Place Removed
— and/or and/or Held
N Hold Address
0
d Date Point of
U) 11 Transportation
p by Common Shipment
Carrier Destination
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 Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped,If Other than Above
a Address
Q
IL1
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/09/2020 Registrar of Vital Statistics JodiL Connall:y(Ekctronican:y Signed
(signature)
District Number 5650 Place Bolton Landing, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IIJDate of Disposition /O/Q Zee-- Place of Disposition 00l )e 0�Gt/ CK�1 4-le
2 (address)
W
N
Q (section) (lot number) j (grave number)
gName of Sexton or Person in C arge of Pre i s ' rt�1 1 '1 o,f I E- �Je- -
'z (please pr/nt)
Signature ��. `4/ Title Cirro'1/p L—
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) O 4 O S 2'
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#