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Stockman Sr., Gerald Howard S2 1[/ NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Gerald Howard Stockman Sr. Male Date of Death Age If Veteran of U.S.Armed Forces, 06/26/2021 79 Years War or Dates F. Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 1260 West Mountain Road 115,Queensbury Town,New York 12804 UJ p Manner of Death ©Natural Cause 0 Accident ❑Homicide ❑Suicide ❑Undetermined Pending W Circumstances Investigation W Medical Certifier Name Title CI Anne Evans DO Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 132 ▪ Burial Date Cemetery,Crematory or Facility Name 06/29/2021 Pine View Crermatorium 0 Entombment Address X❑Cremation Queensbury Town,New York • Donation OZ El Removal Date Place Removed and/or and/or Held F- Hold Address 0 d Date Point of N ❑Transportation p by Common Shipment Carrier Destination EiDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom F— Remains are Shipped,If Other than Above 2 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/28/2021 Registrar of Vital Statistics Caroline.7fi(cfegarce Barber(ECectronicaCCySigned) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I- Z Date of Disposition (o'7�I ij Place of Disposition •Rnc Utz•- 1�-- W (address) W N cc /section/ (lot number) (grave number) c o Name of Sexton or Person in Charge of Premis Z /p(eise print) W c Signature Title " reit DOH-1555(o7/18)p t of 2 Public Health Law Sec. 4145(2b) Eat 14 8 9 5 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#