Peck, John William ) # —)41Z
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records `
Name First Middle Last Sex
John William Peck Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/03/2022 92 Years War or Dates 1955-1957
F— Place of Death Hospital,Institution or
W City,Town or Village Saratoga Town Street Address 31 Condon Rd,Saratoga Town,New York 12170
W Manner of Death 0 Natural Cause Accident Homicide Suicide nUndetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Frank Westad NP
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Saratoga District Number Register Number
City,Town or Village 4565 18
ElBurial Date Cemetery,Crematory or Facility Name
10/05/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
and/or and/or Held
F.a Hold Address
0
a Date Point of
U)❑Transportation
p by Common Shipment
Carrier Destination
ODisinterment Date Cemetery Address
0 Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077
Address
123 Main St,Argyle,New York 12809
Name of Funeral Firm Making Disposition or to Whom
l` Remains are Shipped,If Other than Above
2 Address
CC
W
C1' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/04/2022 Registrar of Vital Statistics Linea 9,fcca6e(ECectronicaCCy Signed)
(signature)
District Number 4565 Place Town Of Saratoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition /WS i a Place of Disposition -N,,,U �
2 (address)
W
N
CC (section) /h t),(lot number) rr (grave num8ber)
11 Name of Sexton or Person in Charge o emises
Z (pie (/� M/u se print)
d7
W Signature Title rroiv
DOH-1555(o7/18)p 1 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#