Peters, Lyman NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Lyman Peters Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/05/2021 87 Years War or Dates Air Force
F_ Place of Death Hospital,Institution or
WCity,Town or Village Kingsbury Town Street Address 501 Dean Road,Kingsbury Town,New York 12839
pManner of Death ❑X Natural Cause ❑Accident ❑Homicide ❑Suicide LiUndetermined Pending
C) Circumstances Investigation
W Medical Certifier Name Title
Gerard Abess MD
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Kingsbury Town 5762 1
0 Burial Date Cemetery,Crematory or Facility Name
01/08/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury,New York
Donation
zRemoval Date Place Removed
and/or and/or Held
H Hold Address
CO
Q. ❑ Date Point of
U) Transportation
by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
5 Address
Q
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/08/2021 Registrar of Vital Statistics Cynthia 4 Barmen(Ekctronica/ysigned)
(signature)
District Number 5762 Place Kingsbury Town, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition / ,9-a02/ Place of Disposition
2 (address) aJ
W
(section) ./ � `(lot nymber) (grave number)
of g Name of Sexton or Person in Charge Premises $4 �d� ,WJO
(please print)
W Signature y� Title (VP S lc
DOH-1555(o7/18)p t of 2
Public Health Law Sec. 4145(2b) 014 394
Receipt
Human remains of delivered on ,
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#