Jeroulis, Gregory NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial _ Transit Permit
Name First Middle Last Sex
Gregory John Jeroulis Male
Date of Death Age If Veteran of U.S. Armed Forces,
7/24/97 78 War or Dates Yes WW2
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 63 Cooper St.
Manner of Death ❑x Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
M Castro Mn
Address
102 Park St- Meng PA11q-NV
—]— -
Death Certificate Filed District Number Register Number
>[ City, Town or Village t-4.5
Date Cemetery or Crematory
:::]: [:]Burial 7/29/97 Pine View Crematorium
®Cremation Address Qieensbur ,NY
FDate Place Removed
❑Removal and/or Held
and/or Address
Hold
Q Date Point of
N❑Transportation Shipment
by Common Destination
Carrier
:::: ❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Sullivan Minahan & Potter 01877
Address
407 Bay Rd. Queensbur ,NY
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above in to .
Date Issued 7/29/97 Registrar of Vital Statistics
(signat re)
District Number 5601 Place Glens FAlls NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
jU Date of Disposition Place of Disposition /�IL� /I�M�T�t'Irylr'l
(address)
UJI
W
t>E (section) (lot number (grave number)
Name of Sext or Person in Charge of P emises „� �( D d4/¢�
g (please print)
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61