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Gardner Jr., John NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section t `< Name First Middle Last, Tv- " \ 1 Sex 1 CN-Nr\ \ N\\core) Gz rA f\z,V i Date of Death ( Age l If Veteran of U.S. Armed Forces, .1 ()(\ Za 2 L.15 ; War or Dates 115Lo -I CI 6 j Place of Death i Hospital, Institution or g, City,C[Qy r Village i Street Address RA- i 2_06Vd y1 Manner of Death i4�Natural Cause fl A cident fl Homicide n Suicide Undete ined Pending �l Circumstances Investigation Medical Certifier Name Title Addresses} et ->•-c4Q 111 \91/4/7 k)'-/ ' zf() t Death Certificate Filed - ��,,_'`` `` District Number l Register Number l' ' Town or Village G.1ee;te r`, � I Date l ► Cemetery or Crematory (,Burial i t 0\©21 2.015 n.2 Vi et►J CQcre�e Address u tJ� 1 \zSvLf :::. C Cremation ��, O� � y Date Place Removed ❑Removal and/or Hold and/or Address Hold 0 1 Date P::int of flei El Transportation i Shipment a by Common Destination Carrier �_Disinterment Date Cemetery Address } U Renterment Date ' Cemetery Address I Permit Issued to f ��Ome i Registration Number y Name of Funeral Home Zaker funeral of l 0 11 Address !i LC cL y ,-tfc Of• , (,ti ,(,SbLi iC.( ; Nuu I"JU!k- l2 Az' Agi Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above ff'¢" Address rm< =<: Permission is hereby granted to dispose of the human r a des ed a as indicated. iN Date Issued Cl-gt) --(� Registrar of Vital Statistics �Oct..` ii `` - ture) District Number c 1 Place /10 t,!/Vx '' ►D I certify that the remains of the decedent identified abov ere disposed of i accorda a with this permit on: tll Date of Disposition 1 0/2/1 5 Place of Disposition ine View Ceme y, Queensbury, NY 2 (address) wfn Hudson 3 51A 1 f,L (section) (lot number) (grave number) AName of Sextor�?or Person in Charge of Premises Connie L. Goedert 4 �f �p (please print) Signature ;,�L 1° 6.€c1e.7 Title Cemetery Superintendent (over) DOH-1555 (9/98)