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Measeck, Peggy Ann NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Peggy Ann Measeck Female Date of Death Age If Veteran of U.S.Armed Forces, 06/08/2021 92 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address 100 Park Street,Glens Falls,New York 12801 p Manner of Death ©Natural Cause ❑Accident El Homicide p Suicide I=1 Undetermined El Pending Circumstances Investigation W Medical Certifier Name Title C3 Anthony Petracca MD Address 3 Ircngate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 244 Burial Date Cemetery,Crematory or Facility Name 06/14/2021 Pine View Cemetery EIEntombment Address EiCremation Queensbury Town,New York ❑Donation 0 Removal Date Place Removed and/or and/or Held - Hold Address N 0 Q. Date Point of N ❑Transportation by Common Shipment Carrier Destination EiDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above M Address CC W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/11/2021 Registrar of Vital Statistics 44)6ert Andrew Curtis(E(ectronicallySigned) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I- W Date of Disposition 6/14/2021 Place of Disposition 21 Quaker Rd Oueenshnry, NY 12804 (address) N Mohican 7C 2 CC (section) (lot number) (grave number) O _ Connie Goedert Name of Se41Lii r Person in Charge of Premises Z n (please print) uJ Signature D Title Superintendent DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 012857 Receipt Human remains of s j. . delivered on "' , 20 ne View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# 2. "1`, Measeck (171F) NAME Peggy Ann Measeck Age: 92 \. Lot Owner: Kenneth L.& Peggy A. Measeck Lot#Mohican 7C Grave# 2 Case: Concrete Died: 6/8/2 0 21 Interred:6.1 4 .2021 Funeral Home: Carletons Cemetery: Pine View