Church, Jerry NEW YORK STATE DEPARTMENT OF HEALTH R 41 (IN
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jerry E. Church Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 16, 2012 66 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address Glens Falls Hospital
Manner of Death mu Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Frances Bollinger, Dr.
Address
161 Carey Rd. Queensbury, NY 12804
Death Certificate Filed District Number Register Number�) 3
City, Town or Village c_ 3
❑Burial Date Cemetery or Crematory
August 17, 2012 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
Date Cemetery Address
El Disinterment
ElReinterment 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
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 8// 7//z Registrar of Vital Statistics CAA-tv-Q W.A-
(signature
District Number:s60 j Place G Fa I s f J97 (a`10 '
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 08/17/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) flot number) (— (grave number)
Name of Sexton or Person in Charge of remises `4o , J0,44-
(phase--print)
Signature Title CV.44Z69
(over)
DOH-1555 (02/2004)