Sherwood 111, Parker Bennett •
NEW YORK STATE DEPARTMENT OF HEALTH '
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Parker Bennett Sherwood III Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/08/2021 70 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W
LU• Manner of Death J Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
CI Asim Chaudry MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 14
Burial Date Cemetery,Crematory or Facility Name
01/12/2021 Pine View Crematory
Entombment Address
0 Cremation Queensbury Town,New York
Donation
c Removal Date Place Removed
and/or and/or Held
Hold Address
N
0
Q. Date Point of
Cl) ❑Transportation
E.) by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
Address
CC
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/12/2021 Registrar of Vital Statistics ',ndert,?ndretu Curtis(Ekctronicallry Signed)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition I/I7L /71 Place of Disposition F.,IL }0--
2 s/
W
U)
CC (section) / ((4tnumber) (grave number)
ci11-
• Name of Sexton or Person in Charge of P ises �w l� hti'f
Z
(p/Ise print)
W Signature ,.�—' Title �2�'"�fT��.
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 0 -4 4 0 3
Receipt
Human remains of `` delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#