Kerr Jr., Edward Nov. 20. 201 / 4:22PM No. 3932 P. 1 ggf
NEW YORK STATE DEPARTMENT OF HEALTH w
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Edward James Kerr Jr DD5 Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/17/2017 78 Years War or Dates 1965-1968
•
Place of Death Hospital, Institution or
City,Town or Village Granville Village Street Address Indian River Rehabilitation And Nursing Center
Manner of Death®Natural Cause 1=IAccident CI Homicide Suicide ri Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Sean Bain MD
Address
17 Madison SI,Grarwige Village,New York 12832
Death Certificate Filed District Number Register Number
City,Town or Village Granville Village 5725 37
❑Burial Date Cemetery or Crematory
11/20/2017 Pine View Crematory
[}Entombment Address
®CrematIon Qlueensbury, New York
Date Place Removed
= n Removal and/or Held
and/or Address •
Hold
Date Point of
[]Transportation _ Shipment
by Common Destination
Carrier •
El
Disinterment Date Cemetery Address
u Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Rogan Denny Stafford Funeral Home 01443
Address
63 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission Is hereby granted to dispose of the human remains described above as Indicated.
Date Issued 11/20/2017 Registrar of Vital Statistics *refund 9tp5rns Efwtmnicaffys
(signature)
District Number 5725 Place Granville Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition /1/21 111 Place of Disposition _ _ ,� (Lce,._.
(address)
(section) IJ (lot number) c (grave number)
Name of Sexton or Person in Charge of Premi s G k,y ' _..)IA.��
jI (p rase print}
Signature '/ Title kt.1M1
(over)
DOH-1555(02/2004)