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Collard, Gerald Raymond NEW YORK STATE DEPARTMENT OF HEALTH - Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Gerald Raymond Collard Male Date of Death Age If Veteran of U.S.Armed Forces, 02/04/2021 65 Years War or Dates 1971-1973 1.. Place of Death Hospital,Institution or WCity,Town or Village Horicon Town Street Address 149 Ernest Smith Road, Horicon Town,New York 12808 p Manner of Death ID Natural Cause ©Accident Homicide ❑Suicide ❑Undetermined El Pending W Circumstances Investigation W Medical Certifier Name Title G Timothy Murphy Coroner Address 52 HAVILAND AVE,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Brant Lake 5654 3 ❑Burial Date Cemetery,Crematory or Facility Name 02/06/2021 Pine View Crematorium ElEntombment Address ElCremation Queensbury Town,New York ElDonation Removal Date Place Removed and/or and/or Held N Hold Address 0 O. Date Point of t/) ❑Transportation Shipment p by Common Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141 Address 9 Pine St,Chestertown,New York 12817 Name of Funeral Firm Making Disposition or to Whom 1-- Remains are Shipped,If Other than Above 2 Address 2 ILI • Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/06/2021 Registrar of Vital Statistics Vista L Wood(E(ectronicarySigned) (signature) District Number 5654 Place Brant Lake, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: / ~ ( 10 • Date of Disposition 21��� Place of Disposition r�� w r 2 (address) W (section) lot number) (grave number) gName of Sexton or Person in Charge of Premises ` '' L Z (pleasAlprintl' /�W Signature l . Title DOH-1555(07/18)p t of 2 Public Health Law Sec. 4145(2b) r 51.3 1 Receipt Human remains of ' • delivered on , 20 1 • Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#