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Hewlett, Gerald NEW YORK STATE DEPARTMENT OF HEALTH i II -t Vital Records Section Burial - Trani Permit Name First Middle Last Sex Gerald J. Hewlett Male Date of Death Age If Veteran of U.S. Armed Forces, °`' Januar 1 2011 95 War or Dates °° Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hos s ital til 0 Manner of Death j�(� Natural Cause Accident i 1 Homicide Suicide ' Undetermined I J Pending J7\ Circumstances Investigation g Medical Certifier Name Title P • 1 a shy- c, 111 Address : Death Certificate Filed ' District Number Repisier Number City, Town or Village Glens Falls,NY 5601 ❑Burial Date Cemetery or Crematory El Entombment Januar 4, 2011 Pine View Cremator Address ©Cremation 1 uaker Road 1 ueensbur , NY 12804 Date Place Removed Z Removal and/or Held 0 and/or Address E" Hold N 0 Date Point of SS [ 1 Transportation Shipment a by Common Destination Carrier ]Disinterment Date Cemetery Address Reinterment Date Cemetery Address ::: Permit Issued to Registration Number H-`n' Name of Funeral Home Sullivan Minahan& Potter 01675 '_§_ Address „-: 407 Ba Road, II ueensbur , NY 12804 twran Name of Funeral Firm Making Disposition or to Whom Ek** Remains are Shipped, If Other than Above 6a Address itd ; ` Permission is hereby granted to dispose of the human remains described above as indicated. ': Date Issued / 13 J i I Registrar of Vital Statistics (, �' ..2,t,�d.)�,,�,, ,,A,� (signature :i='r District Number 5601 Place Glens Falls,NY > I certify that the remains of the decedent identified above were disposed of in accordance/ � with this permit on: LuDate of Disposition 5c q 12cfOPlace of Disposition -! :ne UttW (.,�ric. r'\0v".W (address co Q0 (section) 4r:spoiler(lot num ) (grave number) Name of Sexton or Person in Charg_ of Premises LU z (please print) Signature ,t,� ,",, . Title ci2er1}tUt (over) DOH-1555(02/2004)