Prehoda, Peter NEW YORK STATE DEPARTMENT OF HEALTH ? 333 Vital Records Section Burial - Transit Permit
Name First Miudle Last Sex
Peter Prehoda Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 22, 2014 65 War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Glens Falls Street Address Glens Falls Hospital
10 Manner of Death iLurnX Natural Cause El Accident El Homicide 0 Suicide El Undetermined ri Pending
Circumstances Investigation
W Medical Certifier Name Title
Scott Biasetti, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
r Death Certificate Filed District Number Register Number//,
City, Town or Village 5601 �K1
}❑Burial Date Cemetery or Crematory
May 23, 2014 Pine View Crematorium
t❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
_ Hold
CO Date Point of
c ❑Transportation Shipment
CO by Common Destination
f Carrier
...........
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped, If Other than Above
2 Address
IX
W;
d Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued s /23// -) Registrar of Vital Statistics ll� a"`�W
(signature)
District Number 5601 Place G �i�5 �kAS\, ry
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 05/23/2014 Place of Disposition Quaker Road Queensbury,NY 12804
M? (address)
w
(section) I(lot number) c, (grave number)
ci r
• Name of Sexton or Perso in Charge f Premises rtil e `y'Gnrd
(pl ase print)
Ili YWarit
SignaturePL Title OM
g
(over)
DOH-1555 (02/2004)