Corlew, Peter Town of Queensbury
Certification of Cremation
Pine View Cemetery and Crematory
This certifies that the remains of: Peter Corlew Sr.
were cremated on April , 9 20 15 at the Pine View
(Month) (Day)
Crematorium, Queensbury,New York, and these are the cremated remains of said body.
Date of Death April , 6 20 15 Age 65
(Month) (Day)
Funeral Home MB KILMER Registered No. 263
(Authorized Si ature)
NEW YORK STATE DEPARTMENT OF HEALTH It 2 6,3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Peter Alfred Corlew Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 6, 2015 65 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Suzanne Rayeski, Dr.
Address
170 Warren Street Glens Falls, NY 12801
Death Certificate Filed District Number Register fIV-1)er
City, Town or Village Glens Falls
❑Burial Date Cemetery or Crematory
April 8, 2015 Pine View Crematory
0 Entombment Address
" ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
❑
and/or Address
Hold
Date Point of
0 Transportation Shipment
by Common Destination Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
-} Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby ranted to dispose of the human remains dieyr'be ve indicated.
!0
Date Issued 8 Registrar of Vital Statistics
(signature)
District Number 60/ Place 6%,,+o / /I , y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 04/08/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
CO
(section) A (lot number) (grave number)
Name of Sexton or Person in Charge of Premises `"roc �c
i (please print)Signature ef‘ — Title CrkisPInC
T
(over)
DOH-1555 (02/2004)