Matoon, Jerry W. NEW YORK STATE DEPARTMENT OF HEALTH qjj
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Jerry W. Matoon Male
Date of Death Age �IfVeteran of U.S.Armed Forces,
4/18/20 84War or Dates Korean
Place of Death Hosoital,Institution or
Z City,Town or Village Corinth
W Street Address 625 County Rte. 25
p Manner of Death Natural.Cause Accident Homicide Suicide Undetermined Pending
UCircumstances Investigation
pW Medical Certifier George 5A��kin Title
MD
Address
Palmer Ave., Corinth, NY
Death Certificate Filed District Number Register Number
City,Town or Village
Burial Date Cemetery,Crematory or Facility Name
4/21/20 Pine View Crematory
Entombment Address
❑X Cremation
Donation Quaker Rd., Queensbury, NY
zRemoval Date Place Removed
and/or and/or Held
F-
N Hold Address
n- Date Point of
N ❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Date Cemetery Address
®Reinterment
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home, Inc 00211
Address
24 Church St., Lake Luzerne, NY 12846
Name of Funeral Firm Making Disposition or to Whom
�— Remains are Shipped,If Other than Above
�( Address
�i
W
a
Permission is hereby granted to dispose of the human rem-ains described abq�ve as indicated.
Date Issued Registrar of Vital Statistics -•- .._ F--j C
(signature)
District Number !l`) `'Place C r
i certify that the remains of the decedent identifieu above were disposed of in accordance with this permit on:
F—�
W5 Date of Disposition Z3) D Place of Disposition to IL z1b
2' (address)
W
N
a:, (section) lot number) (grave number)
aName of Sexton or Person in Charge of Pre ses M /wtiilft
Z j (pleas print)
W Signature Title `r"�"ATD
D0N-1555(07/18)p 1 of 2
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#