Kindersley, Peter Bog
NEW YORK STATE DEPARTMENT OF HEALTH-- � Burial - Transit Permit
Vital Records Section
{ Name First Middle Last Sex
Peter Geoffre Kindersle Male
Date of Death Age If Veteran of U.S. Armed Forces,
4: November 8, 2016 89 War or Dates
Place of Death - Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death n Natural Cause n Accident ❑Homicide Suicide n Undetermined n Pending
Circumstances Investigation
' Medical Certifier Name Title
William Cleaver MD
/ Address
t` 100 Park Street Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
u.
City, Town or Village Glens Falls, NY ��j 4r/ `. Y
❑Burial Date Cemetery or Crematory
November 10, 2016 Pine View Crematorium
❑Entombment Address
El Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
N Transportation Shipment
p by Common Destination
Carrier
ri Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
`! Permit Issued to Registration Number
`'Si,‘ Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Si,‘
f2 53 Quaker Road, Queensbury, NY 12804
%? Name of Funeral Firm Making Disposition or to Whom
1'fi Remains are Shipped, If Other than Above
Address
:,6 Permission is ere y granted to dispose of the human mains scribed bovee as in. • •d.
<��� Date Issued �( ]�}�j/(o Registrar of Vital Statistics t ��
' (signature
P
s>r District Number -7,o()/ Place
▪ I certify that the remains of the decedent identified above were disposed of in acco ance with this permit on:
Z lT " Jf-.
W Date of Disposition (]'r��,�, Place of Disposition 'Fa iv+ C
2 (address)
W
co
ce (section) i ,(lot number) (grave number)
pName of Sexton or Person in Charge of Premises try y.,eb"
W4
( lease prin
Signature `( Title cpcimize_
(over)
DOH-1555(02/2004)