Longdaue, Peter NEW YORK STATE DEPARTMENT OF HEALTH t # K4 TO Z
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Peter Jon Longdaue Male
': Date of Death Age If Veteran of U.S. Armed Forces,
n`, November 4, 2015 59 War or Dates
Place of Death Hospital, Institution or
`. City, Town or Village Argyle Street Address 5113 State Route 40
Manner of Death 0 Natural Cause Li Accident 0 Homicide 0 Suicide n Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Elaine Williams,
Address
325 Main Street Hudson Falls, NY 12839
Death Certificate Filed District Number . Register Number
City, Town or Village Argyle 5'15 U 55
0 Burial Date Cemetery or Crematory
November 6, 2015 Pine View Crematory
❑Entombment Address
OTtfi®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
. r7 Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
1. by Common Destination
`' Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home-Argyle 01077
Address
123 Main St., Argyle NY 12809
F Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued /(' (,I 301 s Registrar of Vital Statistics {� iY)"tra,t,-
(signature)
g District Number S-iSQ Place 1 i' I ILA,
cm-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 11/06/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
f
a >• (section) n (lot number (grave number)
ea. Name of Sexton or Person . Charg of Premises Oc `' vim*
(please print)
' Signature Title #46Vigt
(over)
DOH-1555 (02/2004)