White, Gerald NEW YORK STATE DEPARTMENT OF HEAL14H r ' yij
Vital Records Section Burial - Transit P'ermi t
Name First Middle Last Sex
Gerald A. White Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 27, 2017 67 yrs. War or Dates n/a
1- Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
• Manner of Death®Natural Cause D Accident ❑Homicide ❑Suicide El❑Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
G: Paul Bachman MD.
Address
Death Certificate Filetl7 Sycamore, QueensbEiisi i6t I urrfbel. 2804 Register Number
City, Town or Village Glens Falls 5601 _? 56
0Burial Date Cemetery or Crematory
Address
®Cremation Queensbury, NY. 12804
Date Place Removed
Removal and/or Held
and/or Address Y
L.! Hold
+
0 Date Point of
Q Transportation Shipment
d by Common Destination
Carrier ___ _
1:11Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01 1 1 7
Address
18 George St. , PO. Box 277, Fort Ann, NY. 12827
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above
'„ Address
ir
lei
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 6/29/201 7 Registrar of Vital Statistics u jou4yNsa_
t./�'�°.<4,t
(signature)
District Number 5601 Place City of Glens Falls, NY.
1—
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition (o l in Place of Disposition .Pie .,i 6.44,r'r.•..
(address)
tii
VI
CC (section) /'/ (lot number) (grave number)
• Name of Sexton or Person in Charge of P emises G4• S►'"�lll
*fir /J, ( lease print)
Signature I.r( tit.( Title C(4Mt Pit
(over)
DOH-1555 (02/2004)