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Worth, Jerry Allen 4 /vSt) NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jerry Allen Worth Male Date of Death Age If Veteran of U.S.Armed Forces, 12/06/2021 69 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Glens Falls Street Address 6 Kensington Road,Glens Falls, New York 12801 p Manner of Death ©Natural Cause ❑Accident Homicide ❑Suicide ❑Undetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title Robert Reeves MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 579 Burial Date Cemetery,Crematory or Facility Name 12/07/2021 Pine View Crematorium ❑Entombment Address X❑Cremation Queensbury Town,New York EIDonation 0 0 Removal Date Place Removed and/or and/or Held H Hold Address (A O O. Date Point of Cl) ❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Date Cemetery Address Reinterment 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 H Remains are Shipped,If Other than Above a Address CE W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/07/2021 Registrar of Vital Statistics 1Rg6ertAnrdrew Curtis( fectronicaCCy 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: WDate of Disposition n071 Place of Disposition "i .41 2 (address) W CC CC (section) of number) . (grave number) 0 Name of Sexton or Person in Charge of Prem. (pleas print) !L Signature Title f�iC/m617 DOH-1555(07/18)p t of 2 03 .541 Public Health Law Sec. 4145(2b) -• Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on buOal permit Official Funeral Directors Reg.or License# ' `