Crocker, Everard NEW YORK STATE DEPARTMENT OF HEALTH a" 43c_
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Everard Leighton Crocker Male
Date of Death Age If Veteran of U.S. Armed Forces,
JUly 29, 2013 81 — War or Dates WWII
Place of Death Glens Falls o3pi tai Hospital, Institution or Glens Falls Hospital
City, Town or Village Street Address
Manner of Death J Natural Cause E Accident 0 Homicide 0 Suicide Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Jennifer L. Stratton MD
Address
Carey Road Queenshury, Nv
Death Certificate Filed District Numb Registe m er
City, Town or Village Glens Falls L.U/
❑Burial Date Cemetery or Crematory
JUly 30, 2013 Pinp vicw Crpma.tnxg
0 Entombment Address
®Cremation 21 Quaker Road Queenshury, NY 12504
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
0 Transportation Shipment
by Common Destination
Carrier
ElDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01 078
Address
136 Main St. South Glens Falls, NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is h reb granted to dispose of the human remains described above as indicated.
Date Issued 3/ 3 Registrar of Vital Statistics UJ C "1—e. U\J1A-"-e
(signature)
District Number ..5-6a/ Place c7-c'rzJ // /ey 4J v'j
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 1-31-i3 Place of Disposition E,.1 £ faftot-.
(address)
(section) (lot number) S (grave number)
Name of Sexton or Person in Charge of remises Ai-1. • lw�+�`
(pl ase print)
Signature Title CeEt4Ft CUL
(over)
DOH-1555 (02/2004)