Loading...
Brock, Peter Jay .2± 4 ( NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Peter Jay Brock Male Date of Death Age If Veteran of U.S.Armed Forces, 08/04/2021 64 Years War or Dates Air Force H Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital UJ 0 Manner of Death ©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending ILI U Circumstances Investigation E Medical Certifier Name Title Christopher Smith MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 327 ❑Burial Date Cemetery,Crematory or Facility Name 08/06/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury,New York ❑Donation Z ❑Removal Date Place Removed 0and/or and/or Held pN Hold Address ❑Transportation Date Point of a by Common Shipment Carrier Destination Date Cemetery Address ❑Disinterment ❑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 H Remains are Shipped,If Other than Above Z Address Ir W a' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/06/2021 Registrar of Vital Statistics `R96ertAndrew Curtis(Electronically Signed) (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: WDate of Disposition 8 I1114 Place of Disposition •t"i,y(IJ',..r �p.--. 2 (address) W Q (section) (tot number) (grave number) Name of Sexton or Person in Charge of P ses rt 1 L 3tn.tit z (pleas print) 11JSignature Title cm Vat DOH-1555(07/18)p 1 of 2 I o w I Public Health Law Sec. 4145(2b) � '�� �'" Receipt Human remains of delivered on , 20 1 1/ 1 Pine View Cemetery Representing the funeral home named on burial permit 1 Official Funeral Directors Reg.or License#