Gilman, Stanford NEW 4'ORF TATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
':r'' Stanford Gilman Male
'•fr Date of Death Age If Veteran of U.S. Armed Forces,
'r ' May 11, 2014 83 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 19 Pine Street
. Manner of Death I 'Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Philip J. Gara Dr.
"r:r Address
; :;327 Broadway,Fort Edward,NY 12828
Death Certificate Filed District Number inter Number
f City, Town or Village Town of Queensbury 5657
0 Burial Date Cemetery or Crematory
May 16, 2014 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road, Queensbury, ,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
co
0 Date Point of
N Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
ri Reinterment Date Cemetery Address
Permit Issued to Registration Number
; :; Name of Funeral Home Regan Denny Stafford Funeral Home 01443
i:; Address
53 Quaker Road,Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
;t'r':: Remains are Shipped, If Other than Above
;Address
'•.f Permission is hereb granted to dispose of the human r mains described ab ve as indicated.
Date Issued/ I� ( Registrar of Vital Statistics Cam_ (� n-C��
::::::: (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:
W Date of Disposition 5/1 6/1 4 Place of Disposition Pine View Cemetery
2 (address)
W(I) Erie 58A 2
tt (section) aot number) (grave number)
QName of S ton or Person in Charge of Pre ises Connie L. Goe ert
Z (please print)
W Title Superintendent
Signature (Q,Q
(over)
DOH-1555(02/2004)
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