Cameron, Jerrold A NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau.of Vital Records `"' '0,
Name First Middle Last Sex
Jerrold A.Cameron / Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/21/2022 74 Years War or Dates
1_, Place of Death Hospital,Institution or
Z City,Town or Village .Thurman Town Street Address 35 Marble Quarry Road,Thurman Town,New York 12885
UJ
p Manner of Death ❑X Natural Cause Accident ❑Homicide []Suicide Undetermined In Pending
W
V Circumstances Investigation
W Medical Certifier Name Title
G Donald Merrihew MD
Address
"' 319 Bay Road,Queensbury Town,New York 12804
Death Certificate Filed Towq,Of Thurman District Number Register Number
City,Town or Village 5659 8
Burial Date Cemetery,Crematory or Facility Name
e 05/24/2022 Pine View Crematory
Entombment Address
ZCremation Queensbury Town,New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
Date Point of
CO Transportation Shipment
Q by Common
Carrier Destination
Disinterment
Date Cemetery Address
❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/23/2022 Registrar of Vital Statistics Cynthia W,7fyc(e(E(ectronica1Ty Signed)
(signature)
District Number 5659 Place Town Of Thurman
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Il— rr''
Z Date of Disposition SIN !z2 Place of Disposition t'� Zi
W /address
W
Ncc (section) Allot number) (grave number)
gName of Sexton or Person in Charge of Pre/mi s (please ri'nt) lr
z f. Title l ifge
Signature
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
f
r
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# �'