Peltier, Donald Roland NEW YORK STATE DEPARTMENTOFHEALTH J�
Burial- Transit Permit
Bureau of Vital Records
Name First Middle last Sex
Donald Roland Peltier Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/21/2022 84 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
Manner of Death EI Natural Cause ❑Accident 0 Homicide ❑Suicide rillndetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
G Jennifer Donovan DO
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed Town of Queensbury District Number Register Number
Cit ,Town or Vill,iiEl
565
7 77
Burial Date Cemetery,Crematory or Facility Name
04/25/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Z Removal Date Place Removed
and/or and/or Held
F Hold Address
fA
oO„ Date Point of
Transportation Shipment
Q by Common
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
ElReinterment
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F. Remains are Shipped,If Other than Above
5 Address
CC
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/22/2022 Registrar of Vita[Statistics Came'ne.7!1degaastk Bader( ct'n>ru44SO4
/signature/
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition L.)17c i it Place of Disposition /ad + !. rt'—
Ui
bl (section) /!ot numb (grew number)
S Name of Sexton or Person in Charge of Premises A sy
/ ease print)
Z ( �
Ili Signature Title
DOH-1555(07/18)p i of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#