Bromley, Jerry A I 12c
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jerry Herman Bromley Male
Date of Death Age If Veteran of U.S. Armed Forces,
08/11/2012 64 years War or Dates Yes, 1969-1970
i-- Place of Death Hospital, Institution or
W City, Towr Ii Schenectady Street Address Ellis Hospital
a Manner of Death Nlitural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Ili Circumstances Investigation
W Medical Certifier Name Title
C>i I. Volkova
Address
01 Nott Street, Schenectady, New York 12308
Death Ce to Filed District Number Register Number
City, Tow �IIXX Schenectady 4601 727
❑Burial Date Cemetery or Crematory
08/17/2012 Pine View Crematory
❑E ombment Address
demotion Queensbury, N Y
Date Place Removed
❑Removal and/or Held
l'j.� and/or Address
E= Hold
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0 Date Point of
❑Transportation Shipment
Gi by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01203
Address 11 Lafayette Street, Queensbury, New York
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
Iii
> Permission is hereby granted to dispose of the human remains descr ed wO i is zi
v :r; „J:l1r 'u'nR
Date Issued 08/13/2012 Registrar of Vital Statistics
v i —
V
(signature)
illli District Number 4601 Place Schenectady
.>: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lid Date of Disposition -i1-t7_ Place of Disposition ,F11-4, w_! C,yjrw._
2
L (address)
U,
IC (section) 4lot number) / (grave number)
Sis Name of Sexton or Person in Charg of Premises nik e-,4ii-
Z
lease print)
ILI
Signature , Title Oleftl41-0(l..
(over)
DOH-1555 (02/2004)