Ash, Gerald Thomas ,, 7
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NEWYORKSTATEDEPARTMENTOFHEALTH ;r ' Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Gerald Thomas Ash Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/28/2022 82 Years War or Dates 1957-1965
F.. Place of Death Hospital,Institution or
W City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
W
• Manner of Death II Natural Cause Accident Ei Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
CI Carrie Miron PA
Address
319 Broadway,Fort Edward Town, New York 12828
Death Certificate Filed Town Of Fort Edward District Number Register Number
City,Town or Village 5755 81
Burial Date Cemetery,Crematory or Facility Name
10/31/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
DDonation
ZZ❑Removal Date Place Removed
and/or and/or Held
F- Hold Address
N
0
a Date Point of
U)f Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
p— Remains are Shipped,If Other than Above
5. Address
CC
W
O.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/31/2022 Registrar of Vital Statistics Aimee G 9Mafioney(ECectronicatTySigned)
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-
W Date of Disposition JJ/—Zo 2 Z. Place of Disposition /l/e //,'�„J (�'-.-e144,o!�
2 (address)
W
N (section) (lot number) (grave number)
CC / l
W Name of Sexton or Person iJ4/of Premi e s �7 i77L7^� ��/r7ctl
(please print)
W Signature Title A r
DOH-1555(07/18)p 1 of 2
r - �
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#