Elms, Gerald Richard Isl
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Gerald Richard Elms Male
Date of Death Age If Veteran of U.S.Armed Forces,
06/15/2022 75 Years War or Dates 1966-1968
f Place of Death Hospital,Institution or
Z City,Town or Village Granville Town Street Address Slate Ve ,,Center for Rehabilitation and Nursing
ILI
Manner of Death ill Natural Cause Accident El Homicide [liSuicide .Undetermined Pending
111 Circumstances Investigation
gMedical Certifier Name Title
Joshua Starteri NP
Address
10421 State Route 40,Granville Town,New York 12832
Death Certificate Filed Town Of Granville District Number Register Number
City,Town or Village 5756 37
F Burial Date Cemetery,Crematory or Facility Name
06/16/2022 Pineview Crematorium
Entombment Address
Cremation Queensbury Town,New York
iiDonation
O El Removal
Date Place Removed
and/or and/or Held
N Hold Address
0
b Date Point of
t/ ❑Transportation
by Common Shipment
Carrier Destination
EDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
, 18 George St Po Box 277,Fort Ann,New York 12827-0277
Name of Funeral Firm Making Disposition or to Whom
p.. Remains are Shipped,If Other than Above
"2 Address
E
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/16/2022 Registrar of Vital Statistics Jenny Linda M Martelle(Electronically Signed)
(signature)
District Number 5756 Place Town Of Granville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tDate of Disposition 10)(4,1R Place of Disposition -47:‘,�L
X (address)
LU
(section) Alot number) (grave
µ (grave number)
8 Name of Sexton or Person in Charg remises vv r 1
Z (pleas tint)
Signature Title r�'ri'"' e
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) b
Receipt
Human remains ofv L A delivered on ' , 20 -`•
/' / •
Pine View Cemetery Representing the funeral home named/oharial pqrmit
Official Funeral Directors Reg.or License#