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Emery Jr., Jerry P ti 3v NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jerry P Emery Jr Male Date of Death Age If Veteran of U.S.Armed Forces, 12/20/2020 33 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Corinth Village Street Address 116 Maple Street Apt. 1, Corinth Village, New York 12822 Manner of Death ©Natural Cause ElAccident ❑Homicide ❑Suicide ❑Undetermined Pending tV Circumstances Investigation W Medical Certifier Name Title Susan Hayes-Masa Coroner Address 40 McMaster Street,Ballston Spa,New York 12020 Death Certificate Filed District Number Register Number City,Town or Village Corinth 4553 34 ❑Burial Date Cemetery,Crematory or Facility Name 12/23/2020 Pine View Crematory ❑Entombment Address ElCremation Queensbury Town, New York ElDonation 4 El Removal Date Place Removed and/or and/or Held to Hold Address 0 0. Date Point of U) ❑Transportation Q by Common Shipment Carrier Destination 0 Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500, Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom F Remains are Shipped,If Other than Above M Address cr W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/22/2020 Registrar of Vital Statistics Brenda L Peris(Electronically Signed) (signature) District Number 4553 Place Corinth, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H Z Date of Disposition 4,'�3.-7p2c1 Place of Disposition ?/}Z Q t,1/ :.,) t1J (address) W CC N (section) l (lot number)) (grave number) GName of Sexton or Person' ar f Premises th /r "r ��'.y!Ge(,c• Z (please print) lL Signature Title e_/� t/ �'' �/ DOH-1555(07/18)p t of Public Health Law Sec. 4145(2b) 014331 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#