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Peterson Jr., William J
F A- zsc NEW YORK STATE DEPARTMENTO�`HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex 2- William J Peterson Jr. Male Date of Death Age If Veteran of U.S.Armed Forces, 03/14/2023 73 Years War or Dates 1. Place of Death Hospital,Institution or Z City,Town or Village Bolton Town Street Address 29 Woodland Ridge Road, Bolton Town,New York 12814 pMariner of Death Z Natural Cause Accident 0 Homicide Suicide Undetermined Pending Circumstances Investigation W• Medical Certifier Name Title O Lynn Keil PA Address 1340 State Route 9,Lake George Town,New York 12845 Death Certificate Filed Town Of Bolton District Number Register Number City,Town or Village 5650 3 Burial Date Cemetery,Crematory or Facility Name 03/17/2023 Pine View Crematory Entombment — Address ©Cremation Queensbury Town,New York Donation Z Date Place Removed O Removal and/or and/or Held I-- - Hold Address U) 0 CL Date Point of U)ETransportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address EReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander Baker Funeral Home 00037 Address 3809 Main St,Warrensburg,New York 12885 Name of Funeral Firm Making Disposition or to Whom (-. Remains are Shipped,If Other than Above Address CC W .._ a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/17/2023 Registrar of Vital Statistics Jodi(Petteys(E(ectronica((ySigned) (signature) District Number 5650 Place Town Of Bolton I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Disposition �— Place of Disposition YJc'_ ('r ..i i W Date of /, Z�Zj p �; c � r�rGiY7� E (address) W (/) /? (section) (lot nu be� (grave number) � / I O Name of Sexton or Person in Charge of mises a y!//0•'� ( L7 Z g (please print) W Signature s'!! �" �j Title o c /� P DOH-1555(07/18)p 1 of 2 C.) '16 0 0 4 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#