Loading...
Jesmer, Charles Robert 0 it )0— NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Charles Robert Jesmer Male Date of Death Age If Veteran of U.S.Armed Forces, 08/31/2022 74 Years War or Dates i_ Place of Death Hospital,Institution or Z City,Town or Village Harrietstown Town Street Address Adirondack Medical Center-Saranac Lake Site W" Manner of Death ❑X Natural Cause AccidentHomicide 0 Suicide Undetermined ❑Pending V Circumstances Investigation W Medical Certifier Name Title al Elvira Sinodskaya MD Address 2233 State Rte 86 PO Box 471,Harrietstown Town,New York 12983 Death Certificate Filed Town Of Harrietstown District Number Register Number City,Town or Village 1663 81 Burial Date Cemetery,Crematory or Facility Name 09/06/2022 Pine View Crematory Entombment Address Cremation Queensbury,New York Donation ©0Removal Date Place Removed and/or and/or Held E-, Hold Address CO 0 LI. Date Point of Cl)❑Transportation 5 by Common Shipment Carrier Destination Date Cemetery Address DisintermentEl Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom b- Remains are Shipped,If Other than Above M Address III O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/06/2022 Registrar of Vital Statistics Donna KgySay[es(ECectronicallySigned) (signature) District Number 1663 Place Town Of Harrietstown I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition 1 h f 7,Z Place of Disposition et7.,I"-, Cr-AL__ a (address) W I (section) / (lot number) (grave number) SName of Sexton or Person in arge of Premises - , t l zp ase print) Ili rtrSignature ../ Title ����� DOH-1555(07/18)p 1 of 2 • Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#