Geer, Donald NEW,YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Donald Charles Geer Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 9, 2013 94 War or Dates
Place of Death Hospital, Institution or
ui City, Town or Village Street Address 3874 State Route 149
CI Manner of Death ii Natural Cause Accident EI Homicide El Suicide 17 Undetermined Pending
EU Circumstances Investigation
U
W Medical Certifier Name Title
t3, Amy Hogan-Moulton, M.D. Dr.
Address
2 Broad St. Plaza Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village
®Burial Date Cemetery or Crematory
August 15, 2013
❑Entombment Address
❑Cremation
Date Place Removed
Z El
Removal and/or Held
4 and/or Address
E Hold
a Date Point of
0. n Transportation Shipment
(ti by Common Destination
tD Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
—. Remains are Shipped, If Other than Above
2K Address
W r
"' Permission is¢h reby ranted to dispose of the human remai 34. s r'b o .` i'li�` L ed. �O
Date Issued 3 k �j Registrar of Vital StatisticsR),( \ 4gnature)
District Number S-6 \ Place ��
:F-' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W, Date of Disposition 8/1 5/1 3 Place of Disposition Pine View Cemetery
2', (address)
07 Uncas 2864 2
;, (section) (lot number) (grave number)
O Name of Sexto or Person in Char of Premises Connie L. Goedert
A - (please print)
W Signature Z_ . iCrce` Title Superintendent
(over)
DOH-1555 (02/2004)