Coyne, Peter E s
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NEW YORK STATE DEPARTMENT OF HEALTH Burial Transit Permit
Vital Records Section
Name First Middle Last Sex
Peter Coyne Male
Date of Death Age If Veteran of U.S. Armed Forces,
11 / 20 / 2016 78 War or Dates 1956-1959
t- Place of Death Hospital, Institution or
ZCity, Town or Village Wilton Street Address 306 Louden Road
Q Manner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide �Undetermined �Pending
ILI Circumstances Investigation
;U Medical Certifier Name Title
O Edward M. Liebers MD
Address
3 Care Ln # 300, Saratoga Springs, NY 12866
:i Death Certificate Filed District Number>' /�/ Register Number
City, Town or Village Wilton [
El Burial Date I Cemetery or Crematory r
Entombment /��/��/� Pine View Crematory
iiill::Li Address
;.>'E Cremation Queensbury, NY
Date Place Removed
ij❑Removal and/or Held
and/or Address
t Hold
O, Date Point of
Transportation Shipment
C by Common Destination
Mi Carrier
0 Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
iilig Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
Vliiiii Address
iiiiil 402 Maple Ave., Saratoga Sp., NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
af Address
cr.
w
Permission is hereby granted to dispose of the human remai s described above as-indicated.
tiii
ii Date Issued Registrar of Vital Statistics /, ,t, /,k1
�� �(s; tire)
District Number /Of
Place Wilton , New York
ii I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
N
Z
til Date of Disposition )IIZ3//L, Place of Disposition ZnOut-. iitr, 7lars..,
2 (address)
III
0
it (section) /(lot number) ` (grave number)
CIName of Sexton or Person in Charge of Premises 1. t &i, i�
Z (plepase print) •
F Signature �1 Title «'
(over)
DOH-1555 (02/2004)