West, Gerald NEW YORK STATE DEPARTMENT OF HEALTH} ,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gerald Virgil West Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 8, 2014 95 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death IL.] Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined r-i❑ Pending
Circumstances Investigation
T Medical Certifier Name Title
Joseph C. Mihindu, M.D. Dr.
Ai
Address
52 Park St. Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls S 60 ) 5 63
t 0 Burial Date Cemetery or Crematory
December 9, 2014 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
ii
❑ Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward NY 12828
2 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 12 j G ) i 9 Registrar of Vital Statistics �c,,j,.ityy-,2 W
'' (signature)
District Number 5 to ) Place 6 ti5 Tck, AAs/ N U
.-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
' Date of Disposition 12/09/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) pot number) (grave number)
Name of Sexton or Person in Charge f Premises �,rst `5L,+„'r
: , lease print)
Signature Title
(over)
DOH-1555 (02/2004)