Peters Sr., David - 257NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial m Transit Permit
>< Name First • M,1,ddle Last I Sex
DA v i i Go R�ri N t�Tg12S SR • Z /14k
l >„ Date of Death Age If Veteran of U.S. Armed Forces,
: aO I I 7/ War or Dates A/6
14. Place + Death Hospital, Institution or
Citiiiy, Town •r Village Qu(rjrr 5 /t y , Street Address 5MA/le(/ice.L ig4/c—
Manner o Death rt Natural Cause n Accident 0 Homicide 0 Suicide 0 Undetermined Q Pending
ILI Circumstances Investigation
ta Medical Certifier Name Title
CI Acrg J G ill A-A1 lI P
Address
ICIu IAvi I b a, /6.2 PAIN.c7- OkMs go/4 N. y nitro/
De ,Town fcate Filed Di tact miter Regis Number
City, Town r Village t us-_,EAKJ42
i- ❑Burial 1 Date Y Cemetery or Cremato�v
MAR 18 aO T Pair View C2 etr1A1a21i
Entombment}
Address
®Cremation QUAK 'R. RS &U( P4c6 07 , NY /��y
Date dace Removed
C3 CRemoval and/or Held
and/or Address
Hold 1
0 ' Date Point of
EL r—
Transportation I Shipment
by Common Destination
Carrier
n Disinterment Date Cemetery Address
1 ❑Reinterment I Date Cemetery Address
Permit Issued to �7 Registration Number
Name of Funeral Home lr'.\c/V-Y- ,\LtZk, \-NDfil{- C:t k.';L
Address
:<r Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
2 Address
re
li
97 Permission is hereby granted to dispose of the human remains described ab�indicated.
Date Issued a i91 a0) Registrar of Vital Statistics1<)C- ___.�--1
(signature)
District Numbed( "-) Place 1 -c n • • ._
:::..::.
...;:;.:.::
i,s,;.i I certify that the remains of the decedent identified above were disposed of in ac••rdance ith this permit on:
ILI Date of Disposition 3/30/7 Place of Disposition Ztt►siu 0 orivA,
(address)
ta
CC (section) (lot number) (grave number)
tName of Sexton or Person in Charge Premises ihr: r J le 4 ifr
Z / (pi ase print) �-�,�]
Lb Signature ZL /4 Title (( 11t"�
(over)
DOH-1555 (02/2004)