Woerner, Gerald ...
4 • Or'it -
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ge•alcl Woerne• I Male
Date ,:,1 Death Age if Veteran of LI.S. Arrriec F:..-roet.i,
•
, .. Sentemper 25 2014 m" War or Dates
• Place of Death Hospital,Institution or -1
City,LU
-...,ty, Town or Village G. ranville Street Address Indian River F.eneb 4 Nng Center
• manner of Death FiLinceteirri-ined r--1 Pending i
Nature! C;ause Li Accident []Homicide Ej Suicde
1,1.1 !"--'Circumstances !"""'I nvestigatic n
O Medical Certifier Name Tit e
O Sean Bain VD
Address
'ICC+Park St.,Glens Falls,NY 12501
Death Cercate Piled District Number —7 Recister Number
City,Town or Village Grarviie 5725 31
........,__
,.ElBurial i Dale i Cemetery or Crematory
September 30.2C.:i 4 Pre\view Crematory
.! DEntcribmert'l Act:.ess
ZCrernaticn_i I Queenst,.ry,Ny
Date Place Removed
Z 1----1 Removal i and/or Held
/,
- c4"- -',
l Address
1.-
- Hold
tfi i
O Date I Point of
[]Transportation l li Shipment
O by Common ! Destination
Carrier i
,.,.
'I-Cemetery Actrass
''...0 Disinterment i1 Date
i _.[..
j,----1 —tbate 1 Cemetery Acdrass
IL_ Reintertr ent
L 1
Perrnt Issued to 7 Registration Number
... Name o'Funeral Horne WIrox&Recan 01821
_
...,,, Address
11 Aigonkir St Ticonderoga, NY t28L'3
, . Name o'Funeral Firm Making Disoosiion cr tz.1 Whom
.1.-- Remains are Shipped, If Other than Above
2 Address
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t. Permission is hereby granted to dispose of the human remai destribeil abo ,s indicated.
.,.. r
•:' Data issued st:v;e7oer 29,2014 Registrar of Vital Statistics
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i isiv,lavu re)
Dist-ict Number 5726 Place Granvile,NY 12832
la.... I certify that the remains of the dece'lent identified above were cispcsed of in accorcance Iiithi tI's permit..-;n:
2
LLI Date of Disposition 11301114 Place,of Disposition 4,thi....0 Crev•,11>f h.-
2 l'addres,i,.
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IX csectii '/7 oiat r urrb.er) 4'grave ruirrL-er)
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O Name.cy Sexton o-Person' . Charge of Premises a ezill kr. ...celeJti
2 ' ,L_. 1;0,\1., prir0
tit
I Signature 4*-i Title __CPI,Mjgrt
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