Peterson Jr, John NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
7' Name First Middle Last Sex
WJohn F. Peterson,Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
s January 19, 2016 91 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury
'1Street Address The Stanton Nursing & Rehab Center
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
r Suzanne Blood Dr.
1
r. Address
;Mannor Drive,Queensbury,NY 12804
Death Certificate Filed District Number Rater Number
r:; City, Town or Village Queensbury 5657
❑Burial Date Cemetery or Crematory
January 19, 2016 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ I I Removal and/or Held
and/or Address
Hold
tn
0 Date Point of
NI I Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
:: Permit Issued to Registration Number
r Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
' ::r 407 Bay Road, Queensbury, NY 12804
V. Name of Funeral Firm Making Disposition or to Whom
1Remains are Shipped, If Other than Above
Address
:,r Permission i hereby granted to dispose of the human mains described above as indicated.
; l�; Date Issued\ 'a0 1h Registrar of Vital Statistics`` T` q 36(2-'`.,�
r Y (signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 1/z1 /14, Place of Disposition Rat Mt..' ar,, rtor,y#,
W (address)
N
CC (section) /�/ (lotnumber)r (grave number)
ciName of Sexton or Person in Charge of Premises G 1/111;( --)teivti
'Z a "4141-
(over)
(,oiease print)
Signature Title filecM6}134_
DOH-1555(02/2004)