Palmer, Bernard Thomas Sr. , (t...f)rp—....."-----\\ (007/
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
• Bernard Thomas Palmer Sr Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/26/2022 76 Years War or Dates
H Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 42 Main Street,Queensbury Town,New York 12804
0 Manner of Death a Natural Cause Accident Homicide OSuicide 1=1Undetermined ❑Pending
Ui
0 Circumstances Investigation
111 G Medical Certifier Name Title
Alexis Mondella NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 112
Burial Date Cemetery,Crematory or Facility Name
07/29/2022 Pine View Crematory
Entombment Address
Cremation Queensbury,New York
El
❑Donation
Z Date Place Removed
,0❑
and/or
Removal and/or Held
~ Hold Address
(I)❑Transportation Date Point of
ZS by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment mt Date Cemetery Address
• Permit Issued to Registration Number
" Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
' Name of Funeral Firm Making Disposition or to Whom
14,1 Remains are Shipped,If Other than Above
Address
I Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/29/2022 Registrar of Vital Statistics Caroline 2fiCdegarefe Barber g(ectmnica1TySigned)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 7-3?-?ptZ (/Place of Disposition i A)e e) Cf`,e,t.ij--t-
X (address)
Ili
re (section) (lot nupber) 1 (grave number)
Q Name of Sexton or Person in Charge o remises Ki4 '#yf t 41 Wee
z (please print)
Signature Title 0 tex-4,40 —
DOH-1555(07/18)pi of 2
Public Health Law Sec. 4145(2b)
1 Receipt
i
Human remains of delivered on , 20
1
r
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#