Palmer, Gary . . \ li 5L(3
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NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gary L. Palmer Male
Date of Death I Age 1 If Veteran of U.S. Armed Forces,
October 11,2012 1 55 War or Dates
Place of Death Hospital, Institution or
,Z City, Town or Village Glens Falls 1 Street Address Glens Falls Hospital
Manner of Death X Natural Cause I 'Accident Homicide Suicide Undetermined Pending
w Circumstances Investigation
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u1 Medical Certifier Name Title
0 Ageel Gillani
Address
CR Wood Cancer Center,102 Park St.,Glens Falls,NY 12801
Death Certificate Filed 1 District Number Register Number
City, Town or Village Glens Falls 5601 1.4 7
❑Burial Date Cemetery or Crematory
October 12,2012 Pine View Crematory
❑Entombment Address
0 Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
F Hold
N
0 Date j Point of
coTransportation ( Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
I I 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
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Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued } 2®/ r `( -2_ Registrar of Vital Statistics LA,7Gt..kiry.9 U0 l
(sign ure)
District Number 5601 Place Glens Falls
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ui Date of Disposition IU-Ib-►7_ Place of Disposition ,.rt)Ur44 C i<,►.-,
2 (address)
W
U) (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge Premises I --r'J Sokaii-
Z (please print)
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Signature ._ Title C'auvittiT 2.
(over)
DOH-1555 (02/2004)