Gardineer, Peter J t , V )l 5-Cli
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last I Sex
<.-I Peter Edgar Gardiner I Male
Date of Death I Age If Veteran of U.S.Armed Forces,
07/06/2015 L 82 War or Dates Korea Place of Death �9,j Ai,(hj,�,` Hospital, Institution or ,�" cr /va/j,qda
City,Town or Village NomparEgriek Street Address Deceased's Residence
Manner of Death a Natural Cause Accident 0 Homicide El Suicide 0Undetermined 0 Pending
Circumstances Investigation
Medical Certifier Nameted/ ()n itle
7 4 / ? �-�OAd• -.siy(9/, , �
764
� �
I Death • irate Filed ,,-- ,( District ml ber Register Number
t" City, • �� or Village "Si 2-if/)✓`�'' v� _ 3
�' 0 Burial Date / Ce tery or p�r matory /v
07/08/2015 /Pia v v f tc/ `/'17 / `I) ii litij
❑Entombment Address ,r
Or 0Cremation ( .-e z4,.f 1/ir' .(/.7 l e9 4I
Date Place Removed
Removal and/or Held
and/or
Hold Address
Date Point of
7 0 Transportation Shipment
‘,1 by Common Destination
"` Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
�t Permit Issued to Registration Number
f 'i) Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
t4r
Address
kolt
9 Pine St/P.O. Box 455 Chestertown NY 12817
J:y 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 r ins 5alscrib d above as in icated.
u Date Issued�tx�� �Registrar of Vital Statistics L_,
rgnature
AS
, District Number Place �t Q} , ' dNUT ,
,ks; I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
r , Date of Disposition 7)5 i l c Place of Disposition -Yr4.7./ eCofl�..4
(address)
: (section) (lot number (grave number)
At
Name of Sexton or Person in Cha a of Premises
please print)
,, Signature Title 62,Cottiltel-
(over)
DOH-1555(02/2004)
S