Annis, Gerald NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gerald E. Annis Male
Date of Death Age 1 If Veteran of U.S. Armed Forces,
March 27,2014 59 f War or Dates
1.. Place of Death Hospital, Institution or
'Z City, Town or Village Glens Falls j Street Address Glens Falls Hospital
p Manner of Death g Natural Cause Accident Homicide Suicide Undetermined Pending
w Circumstances Investigation
W Medical Certifier Name Title
0
Address
Death Certificate Filed District Number Regist9rr Nlimber
City, Town or Village Glens Falls 5601 A.
❑Burial Date 1 Cemetery or Crematory
❑Entombment I March 31,2014 j Pine View Crematory
Address
El Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
Hold
a Date i Point of
co Transportation ! Shipment
a by Common Destination
Carrier
Disinterment Date ' Cemetery Address
j Reinterment Date Cemetery Address
I
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home I
00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
2 Address
C
w
O. Permission is hereby granted to dispose of the human remains described above ass indicated.
Date Issued 3I S I /f 1-/ Registrar of Vital Statistics (A.) CA1�y-%.R U3
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Iti Date of Disposition 3)31)iq Place of Disposition Ut,/ (.rI-r/tar,u,..
W (address)
CO
CL (section) dris*-
(lotnumber] (grave number)
aName of Sexton or Person i Charge of remises trait.`Z (pe print)
Signature ! f Title CM.P471117
(over)
DOH-1555 (02/2004)