Palmer Jr., Walter NEW YORK STATE DEPARTMENT OF HEALTH it
Vital Records Section Burial - Transit Per it
Name First Middle Last Sex
Walter Clark Palmer Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
0 5/2 7/2 01 7 62 ----War or Dates
Place of Death Hospital, Institution or
ZCity, Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death it Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined Ei❑Pending
W Circumstances Investigation
Ili Medical Certifier Name Title
Kyle S. Leonard MD
Address
161 Carey Rd. Queensbury, NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5 b(9 1 2-C15
> >0 Burial Date Cemetery or Crematory
05/ 30/ 2017 Pine View Crematory
❑Entombment Address
g®Cremation Quaker Rd. Queensbury, NY 1 2804
Date Place Removed
Removal and/or Held
2❑and/or Address
-
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Hold
O Date Point of
41,6 El Transportation Shipment
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Edward L. Kelly FH 00519
Address
Schroon Lake, NY 12870
: Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
Ili
IIti
` Permission is hereby granted to dispose of the human remains described above as indicated.
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Date Issued 5 1 c) ((7 Registrar of Vital Statistics ced` . k.A..)
(signature)
District Number 5601 Place 6 ( rs$ fZ1 \\ S
r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition S D.3) i 0 Place of Disposition grt0;.. /7; „VI-e*....,,
2 (address)
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CO
CC (section) /t.(lot number) (grave number)
Name of Sexton or Person in Charge of Premises /4tis it S'AAlif
2 (ple se print)
Signature 2/ 4 Title int01Pgr,
(over)
DOH-1555 (02/2004)