Goodspeed, Peter # 3
NEW YORK STATE DEPARTMENT OF HEALTH ' * q,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Peter D. Goodspeed Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 27,2016 72 War or Dates
F- Place of Death Hospital, Institution or
Z City, Town or Village Johnsburg Street Address 2710 State Route 28
p° Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
O Jennifer Donovan
Address
HUHN,Johnsburg,NY 12843
Death Certificate Filed District Number RegistA Number
City, Town or Village Johnsburg 5655 I ( -
❑Burial Date Cemetery or Crematory
May 31,2016 Pine View Crematory
El Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
ZO n Removal and/or Held
and/or Address
H Hold
O Date Point of
0 I 1 Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
-, Remains are Shipped, If Other than Above
2° Address
11.1
Permission is hereby))granted to dispose of the human m ins d crib d above a indicated.
Date Issued-5 W 6
1" Registrar of Vital Statistics . _
_ (signa )
District Number St 3j Place ®1 1\D < (I\`(\
I certify that the remains of the decedent identified above were disposed of in accordan with this permit on:
W Date of Disposition 6 / Place of Disposition &1 �, .arw...
2 (a dress)
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Cl)
re (section) (lot number) (grave number)
pName of Sexton or Person in Charge of remises dfn: jo. f
�Z please punt)
Signature ( Title ME MAN
(over)
DOH-1555 (02/2004)