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Petersen, Andrew NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial _ Transit Permit Name First Middle Last Sex Andrew Petersen Jr, Male Date of Death Age If Veteran of U.S. Armed Forces, Jan 29, 1996 73 War or Dates WWII Place of Death City of Glens Falls Hospital, Institution or Glens FAlls Hospital City, Town or Village Street Address Manner of Death ®Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation Medical Certifier Name Title Chareles Lowe MID Address Broad St. Glens FAlls, New York 12801 Death Certificate Filed District Number Register Number City, Town or Village City of Glens Falls 5601 6 q Date Jan 31, 1996 Cemetery or Crematory ❑Burial Pine View Crematory Address ©Cremation Tn. of Queensbury, New York Date Place Removed Z❑Removal and/or Held -- and/or Address Hold Q Date Point of NQ Transportation Shipment by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home McClellan Fueneral Service 1244 Address East Broadway Salem, New York 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 ae�cribed above asinoicated. Date Issued Jan 31, 1996 Registrar of Vital Statistics (signature) District Number 5601 Place City of Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: r LU Date of Disposition : Place of Disposition /Pit�� ;�`k'� 1 (address) Uj (section) (lot number) (grave number) GName of Sextorlor Person in Charge of P emises ��,� � / . (please print) Signature Title�` � � DOH-1555 (10/89) p. 1 of 2 VS-61