Splain, Peter NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
«> Name First Middle Last Sex
Peter G. Splain M
>' Date of Death Age If Veteran of U.S. Armed Forces,
11/15/95 53 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Town of Wilton Street Address 550 Maple Ave.
Manner of Death❑Natural Cause Accident Homicide Q Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
J. Paston M.D.
Address
24 Church St. Saratoga ri NY 12866
Death Certificate Filed District Number Register Number
City, Town or Village Town of Wilton NY 4569 10
Date Cemetery or Crematory
u Burial November 20 1995 Pine View Crematory
Fx
Cremation Address
Queensbury, NY
El1 Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
[]Reinterment Date Cemetery Address
Permit Issued to Reg26r tion Number
Name of Funeral Home Wi lliam J. Burke & Sons Funeral Home 0000
-.` Address
628 North Broadway Saratoga Springs, W
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission I;;Fz«Wji 9sar' ed la d;-Pv.- of the �:l:�nart r^. ainc �pS . a .�rl ah�+.,o as-irrliratgr�.
Date Issued 11 (� Registrar of Vital St 'c
(signat e)
District Number 4569 Place Town of Wilton , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
,p t
Date of Disposition/ Place of Disposition ����j(/�
(address)
(section) (lot number) (grave number)
Name of Sexton 91 Person in Charge of Pre ises ��L Z0 4 7 V/9A,)
(please print) l
Signature Title t ,/
DOH-1555 (10/89) p. 1 of 2 VS-61