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Decari, Jerry A
NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jerry A.Decarli Male Date of Death Age If Veteran of U.S.Armed Forces, 10/03/2021 38 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Saratoga Springs Street Address Saratoga Hospital WW Manner of Death El Natural Cause 1=1 Accident I=1 Homicide El Suicide Undetermined ©Pending Circumstances Investigation Q Medical Certifier Name Title Robert Ball Coroner Address 10 Glen Eagles Blvd,Ballston Lake,New York 12019 Death Certificate Filed District Number Register Number City,Town or Village Saratoga Springs 4501 567 ❑Burial Date Cemetery,Crematory or Facility Name 10/08/2021 Pine View Crematory Entombment Address lCremation Queensbury Town,New York ❑Donation ElRemoval Date Place Removed and/or and/or Held H Hold Address 0 d 1-1 Date Point of f/) ❑Transportation p by Common Shipment Carrier Destination ❑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 H Remains are Shipped,If Other than Above 5 Address CC W a. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/05/2021 Registrar of Vital Statistics John Paul Franck(Electronically Signed) (signature) District Number 4501 Place Saratoga Springs, 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 /e2-9-ioZ/ Place of Disposition e 4 Q U;Q,,J Crern,440 J`tiS 2 (address) W CCCC (section) (lot nu er) (grave number) a Name of Sexton or Person in Char of Premi s '---RIgYNZOvs Ci G( l Z g / �() '��,,[_ (please print) W Signature r� 1I'*' Title d + DOH-1555(07/18)p 1 of 2 A 1 91521 Public Health Law Sec. 4145(2b) Receipt i Human remains of a delivered on , 20` _: Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#