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Bombard, Peter Horace I g NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Peter Horace Bombard Male Date of Death Age If Veteran of U.S.Armed Forces, 02/19/2023 79 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Kingsbury Town Street Address 916 Vaughn Road,Kingsbury Town, New York 12839 11 • Manner of Death ZI Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation 0 Medical Certifier Name Title Thomas Coppens MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed Town Of Kingsbury District Number Register Number City,Town or Village 5762 5 Burial Date Cemetery,Crematory or Facility Name 02/21/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation ZO❑Removal Date Place Removed and/or and/or Held ~ Hold Address N 0 O. Date Point of Cl) Transportation E5 by Common Shipment Carrier Destination EIDisinterment Date Cemetery Address Reinterment Date Cemetery Address 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 1— Remains are Shipped,If Other than Above g Address CC O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/21/2023 Registrar of Vital Statistics Cynthia Bar1in(ECectronicaltySigned) (signature) District Number 5762 Place Town Of Kingsbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 21 z3 73 Place of Disposition '<v.V 2 (address/ W Cl) (section) (lot number) , (grave number) SName of Sexton or Person in Charge of Prem. /t^ L t It Z (p se print/ W Signature Title A ►'r11111 DOH-1555(07/18)pi.of 2 i _ 1 ` ._, t 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#