St.Peters, Richard # SS'---
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Richard St.Peters _ Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/04/2021 77 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Saratoga Springs Street Address 11 Pleasant Drive,Saratoga Springs,New York 12866
p Manner of Death Natural Cause 0 Accident ❑Homicide El Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Susan Hayes-Masa Coroner
Address
40 McMaster Street,Ballston Spa Village,New York 12020
Death Certificate Filed District Number Register Number
City,Town or Village Saratoga Springs 4501 368
Burial Date Cemetery,Crematory or Facility Name
07/07/2021 Pine View Crematory
Entombment Address
gCremation Queensbury Town,New York
Donation
Z Date Place Removed
8 0 Removal and/or Held
— and/or
N
Hold Address
dDate Point of
U) ❑Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
0 Disinterment
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home William J Burke&Sons Funeral Home 01827
Address
628 N Broadway,Saratoga Springs,New York 12866
Name of Funeral Firm Making Disposition or to Whom
�_. Remains are Shipped,If Other than Above
Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/07/2021 Registrar of Vital Statistics Jo/u,l'uuiFraurk(LIeCtrnurrallySgued)
(signature)
District Number 4501 Place Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition in ill Place of Disposition
W
2 (address)
W
CC U) (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Prem. s — nct SO44 —
Z -- / ase print) ,/f
W Signature _. Title _____ 1 �'\
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