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Peck, Jane A
# 38g NEW YORK STATE DEPARTMENT OF HEALTH a Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jane A.Peck Female Date of Death Age If Veteran of U.S.Armed Forces, 04/29/2023 61 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital ILI p Manner of Death []Natural Cause []Accident []Homicide Suicide Undetermined ❑Pending ` I Circumstances Investigation W Medical Certifier Name Title 121 Shahid Ahmed MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed City Of Glens Falls District Number Register Number City,Town or Village 5601 221 [ ]Burial Date Cemetery,Crematory or Facility Name 05/02/2023 Pine View Crematorium []Entombment Address ©Cremation Queensbury Town, New York Donation Z Removal Date Place Removed ❑- and/or and/or Held H- Hold Address 0 d Date Point of (/)[]Transportation p by Common Shipment Carrier Destination []Disinterment Date Cemetery Address []Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home William J Burke&Sons Funeral Home 01827 Address • 628 N Broadway,Saratoga Springs,New York 12866 Name of Funeral Firm Making Disposition or to Whom ▪ Remains are Shipped,If Other than Above Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/02/2023 Registrar of Vital Statistics Megan.'olsn gkctranicallySgned) (signature) District Number 5601 Place City Of Glens Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ?it l— 7 Z Date of Disposition 5 jj)j,3 Place of Disposition LLI (address/ W CC CC (section) (tot number) (grave number) Name of Sexton or Person in Charge of P ises //L (pie se print) Z W Signature Title Arfe' � DOH-1555(07/18)p i of 2 • rea 1 }r Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit 1 Official Funeral Directors Reg.or License#