Sebald, Jerry t �
311
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jerry Earl Sebald Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 15,2012 79 War or Dates Korean
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
LI) Circumstances Investigation
C)
W Medical Certifier Name Title
0 Paul Bachman
Address
HHIIN,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 Z,Sfj
❑Burial Date Cemetery or Crematory
Entombment Address
18,2012 Pine View Crematory
Address
1I Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
Hold
O Date Point of
a.
Transportation Shipment
a 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 00035
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
W
a
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 61 i ?/f z Registrar of Vital Statistics C (' . ,
gature�J` ) V
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:
W Date of Disposition 411(1(2. Place of Disposition , ��,,, 6vorrio r wv.
W (address)
co
(section) /J (lot numbe (grave number)
pName of Sexton or Person in Charge of Premises L hu r (4D4/f"
Z ` (please print)
w Signature ./Y s Title GUL' A•To�
(over)
DOH-1555 (02/2004)