Palmer, Jerry Leon ._ .LF ,
c----- A- 71
NEW YORK STATE DEPARTMENT OF HEALTH , . Burial - Transit Permit
Bureau of Vital.Records
Name First Middle Last Sex
Jerry Leon Palmer Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/05/2022 74 Years War or Dates _M
i_ Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death a Natural Cause Accident Homicide []Suicide []Undetermined []Pending
LLJ I (Circumstances ' 'Investigation
U
W Medical Certifier Name Title
p Kelly Maley PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 608
Burial Date Cemetery,Crematory or Facility Name
12/07/2022 Pine View Crematorium
Entombment Address
[]Cremation Queensbury Town,New York
Donation
0Z Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
Ct. Date Point of
N Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
5 Address
CC
LLJ
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/07/2022 Registrar of Vital Statistics LMegan Nolin(Electronically Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t—
W Date of Disposition I2 j Yi ZZ Place of Disposition
2 (address)
W
CC (section) /j�/ (lot number/ (grave number)
p Name of Sexton or Person in Charge • miles G/"//1" \G^�.•
Z lease print)
W Signature Title "`''Th4
DOH-1555(07/18)p i of 2
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#