Granger, Gerald NEW YORK STATE DEPARTMENT OF HEALTH A&WI
Vital Records Section Burial - Transit Permit
' Name First Middle Last Sex
Gerald F. Granger Male
Date of Death Age If Veteran of U.S. Armed Forces,
09/14/2016 65 War or Dates
01 Place of Death Hospital, Institution or
0-11 City, Town or Village Brant Lake Street Address Deceased's Residence
Manner of Death j Natural Cause 0 Accident D Homicide El Suicide 0 Undetermined ri Pending
Circumstances Investigation
Medical Certifier Ahl ame r/ L. Title
///'- C��l/ \A/61 c
g; s/
4e, �/7,>-/
Death - icate Filed is�ct Number Register Number
4)
IOC a City, • "+ •rVillage f/C ex -, . J6,54f t
A i❑Burial Date et-II-:-► or Cre tory —�
09/16/2016 "'�/17-Pi ve" ("2e0,07 ct/d ri an/
�, ❑Entombment Address
s " ®Cremation OP _:/ ) C4
t Date 'lace Removed
,:-, Removal and/or Held
and/or Address
Hold
11070
Date Point of
00,4 ❑Transportation Shipment
1. by Common Destination
Carrier
10 4,1, Disinterment
Date Cemetery Address
k
Reinterment Date Cemetery Address
w
Permit issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
A Address
_ 9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
• t Remains are Shipped, If Other than Above
Address
44 Permission is hereby granted to dispose of the human rem ins escribed above as in h'cated.
1 -
Date Issued q_15-/' Registrar of Vital Statistics � ��
(signature)
t District Number Place—ww, C.-6-v--
vi I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
, ,
Date of Disposition 1II1It Place of Disposition ,Ko,tm, 1n4,t0(t+4
s ,, (address)
(section) 1 (lot number) (grave number)
' y Name of Sexton or Person in Charge f Premises �� i well
(please print)
Signature L'L Title (121t1)
(over)
DOH-1555(02/2004)