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Peterson, Lenora F Rio i7 .01► NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Lenore F. Petersen Female Date of Death Age If Veteran of U.S.Armed Forces, 12/27/2023 88 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Johnsburg Town Street Address Elderwood at North Creek 111• Manner of Death El Natural Cause Accident ❑Homicide Suicide Undetermined Pending U Circumstances Investigation LU Medical Certifier Name Title James Hindson MD Address 112 Ski Bowl Rd,Johnsburg Town,New York 12853 Death Certificate Filed Town Of Johnsburg District Number Register Number City,Town or Village 5655 57 Burial Date Cemetery,Crematory or Facility Name 12/28/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation Z Removal Date Place Removed and/or and/or Held - Hold Address 0 o- Date Point of Cl) Transportation by Common Shipment Carrier Destination Date Cemetery Address Disinterment Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom ▪ Remains are Shipped,If Other than Above g Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/28/2023 Registrar of Vital Statistics Jean M Comstock(Electronically Signed) (signature) District Number 5655 Place Town Of Johnsburg I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition /1 . 3— Place of Disposition p �i 4.) Ci'.i 7� e t� 2 (address) W CC CC (section) (lot number) (grave number) � 1_J ci• Name of Sexton or Person in Charge Premi '\ ��m�� fd,L Z (please print) W rtepS?4ar— Signature Title 0 DOH-1555(07/18)p 1 of 2 017796 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#