Tierney, Patrick Peter NEW YORK STATE DEPARTMENT OF HEALTH6---')F
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Patrick Peter Tiemey Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/07/2024 90 Years War or Dates 1954-1962
H Place of Death Hospital,Institution or
Z City,Town or Village Moreau Town Street Address 198 Bluebird Road,Moreau Town,New York 12803
IIJ
p• Manner of Death ID Natural Cause ❑Accident Homicide Suicide Undetermined Pending
V I—ICircumstances Investigation
WG Medical Certifier Name Title
Sonya Blackmer NP
Address
2 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed Town Of Moreau District Number Register Number
City,Town or Village 4562 4
LBurial Date Cemetery,Crematory or Facility Name
01/12/2024 Pine View Cemetery
Entombment
_ Address
Cremation Queensbury Town,New York
Donation
O Removal Date Place Removed
and/or and/or Held
F Hold Address
CO
0
d Date Point of
(0)❑Transportation
p 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
ii— Remains are Shipped,If Other than Above
2 Address
Q
WI
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/09/2024 Registrar of Vital Statistics Brenda Nfutter(E(ectronicaCCy Signed)
(signature)
District Number 4562 Place Town Of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:I—
Z Date of Disposition t- 1 -d a 4 Place of Disposition c7 I CAL k<_..- WO 6.4 lc zf 1 S 1-j0 r i I Y�I I 0)804
ILI
(address) I/
U J 5;ie. 13E
fL (section)
---- / (tot number) l (grave number)
gName of Sexton or Person in Charge of Premises , _o nni e-, 1-c-'c-dk-iZ-`
Z (please print)
W C_
Signature ,1 e 4. Title -k A;mac,:\4A -tic th.
DOH-1555(07/18)p 1 of 2
01.7414
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
f
o
iP ne View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
TIERNEY/HOSKINS 4:()
Owner
Patrick Tierney-Donna Hoskins
Address Plot
1276 Ridge Road Queensbury NY 12804 Erie
Phone # Lot #
51 8-793-61 51 / 51 8-683-1 982 13-E
Deed # Date
4033 1 /1 6/201 8
Cost Foundation Y - N
1200
Location
Bounded to the West by Gonyea,Vacant, to the North by
Yattaw, East by Eggleston, and South by Path
Remarks
Record of Interments
.1 • awl
2 `� 7
Patricia Tierney 1 /1V2018(FB)
3 8
4 9
5 10
Con vet_ V At-AJr
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TIERNEY
NAME Patrick Peter Tierney Age: 90
Lot Owner: Patrick Tiweney-Donna Hoskins
Lot# Erie 1 3E Grave# 1
Case: Concrete44!)
Died: 1 .7.2 4 Interred:1 1 2 2 4
Funeral Home: Baker FH
Cemetery: Pine View