Carr, Gerald NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gerald Carr Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 11, 2012 54 War or Dates
Place of Death Hospital, Institution or
i
City, Town or Village Queensbury Street Address 6 Sylvan Ave.
ci Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
US Circumstances Investigation
us Medical Certifier Name Title
Pi. Dr. Gilliani,MD
Address
102 Park Street,Glens Falls,NY 12804
:'; Death Certificate Filed ' trictt Number Register' Number
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City, Town or Village Queensbury `--)
❑Burial Date Cemetery or Crematory
December 14, 2012 Pine View Cremation
❑Entombment Address
CI Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F- Hold
U)
O Date Point of
U) Transportation Shipment
p' by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
14! Remains are Shipped, If Other than Above
'N,b' Address
tie
us
• Permission is hereby granted to dispose of the human r m ins described abov as indicated.
Date Issued lc�-) 131 llc,/10)a;Registrar of Vital Statistics Ci, ll,c.�--..._
(signature)
District Numbers-( 7 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Date of Disposition ►Z.-t$-�Z Place of Disposition ,,.��.c�J �•r+.+�„�.,ips�
2 (address)
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CC
O (section) At
(lot number (grave number)
p Name of Sexton or Person in Charge of Premises S ,
Z (please print)
W
Signature _ Title C g.
(over)
DOH-1555(02/2004)