Arnold, Gerald tt
NEW YORK STATE DEPARTMENT OF HEALTH ��"3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gerald Arnold Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 19,2014 57 War or Dates
t.._ Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
QManner of Death g Natural Cause Accident Homicide Suicide Undetermined Pending
tia Circumstances Investigation
ku Medical Certifier Name Title
Michael Fuller
Address
100 Park St.,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 iq 9
❑Burial Date Cemetery or Crematory
April 22,2014 Pine View Crematory
II Entombment Address
❑x Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z
Removal and/or Held
and/or Address
H Hold
O Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above
Address
tY
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 4 (ZZ`1' Registrar of Vital Statistics `
(signature)
District Number 5601 Place Glens Falls N y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ul f Date of Disposition H A ill Place of Disposition I„�,u;;,.1 or '
(address)
W
N
(section) AI t numbers (grave number)
pName of Sexton or Person in Charge of Premises 6r,� t\mit-
Z (please print)
ILI
Signature Title (WIMPfl
(over)
DOH-1555 (02/2004)