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Jackson, Gerald Francis
4 ./r gll NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Gerald Francis Jackson Male Date of Death Age If Veteran of U.S.Armed Forces, 10/23/2021 73 Years War or Dates F_ Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital w Undetermined Pending W Manner of Death © Natural Cause E Accident 0 Homicide �Suicide Circumstances Investigation W Medical Certifier Name Title 0 Christopher Smith MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 463 ElBurial Date Cemetery,Crematory or Facility Name 10/27/2021 Pine View Crematory ❑Entombment Address ElCremation Queensbury Town,New York EiDonation Z Removal Date Place Removed and/or and/or Held H Hold Address • N 0 a. Date Point of tl') ❑Transportation 0 by Common Shipment Carrier Destination IEI Disinterment Date Cemetery Address El 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 }- Remains are Shipped,If Other than Above 2 Address Q Illl O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/27/2021 Registrar of Vital Statistics `R9bertAnclrew Curtis(Electronically 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: I— � ' Z Date of Disposition /0 hiti.I Place of Disposition gut!W (address) ~ �- W CD CC (section) (lotnumber) (grave number) a Name of Sexton or Person in Charge of Premises A L ` O (p/ere print) W r� Signature Title DOH-1555(07/18)p 1 of 2 �11 7 6 3 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#