Merrett, Peter NEW YORK STATE DEPARTMENT OF HEALTH / 1 itSW
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Peter G. Merrett Male
Date of Death Age If Veteran of U.S. Armed Forces
,,A,,,,,,,„
" 08/17/2014 85 War or Dates Yf L7—�)7�
Place of Death Hospital, Institution or S`�C�c�c,l c7`--
r_ City, Town or Village Queensbury Street Address Deceased's Residence
oh Manner of Death 0 Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Carrie Mirar, PA t'_
Address
9 Carey Rd Queensbury, NY 12804
City ificate Filed l J /i Di�txict�u r R r Number
City Tow or Village ( V / 5 ' J
❑Burial Date Ce tery or gre�atory �,
08/18/2014 ,ice v(-et.cic riew g/0v1 _
❑Entombment Address
R.®Cremation f AL/6.7 - (Z_7 1-P622/
Date Place Removed
isiAd❑ Removal
and/or and/or Held
Hold
dress
.pi
0" Date Point of
❑Transportation Shipment
by Common Destination
1 Carrier
LI Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
x' Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
' Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
tf Name of Funeral Firm Making Disposition or to Whom
;.;as
, Remains are Shipped, If Other than Above
.k Address
A Permission is hereby granted to dispose of the human r mains described ab ire as indilcated.
Date Issued V 1 1 )t Registrar of Vital Statistics c,__ 0-4,
—; (signature)
District NumbC(gS Place I C.)-u/--a— O F
I certify that the remains of the decedent identified above were disposed of in actor a with this permit on:
I k �
'- Date of Disposition gf AIN Place of Disposition 'I�nat,L 1 C ,{ot1-
,,
(address)
(section) / of number)(( (grave number)
gob
/Ird t .lont*.; Name of Sexton or Person in Charge of Premises p�-
1 (please print)
Signature C` /fr Title CiNinVie
(over)
DOH-1555 (02/2004)