Gilbertson, Jon NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
' Name First
Middle Last Sex
>: Jon Culver Gilbertson Male
ply:
Date of Death Age If Veteran of U.S. Armed Forces,
0 A I ri125 2015 76 War or Dates
Place of Death Hospital, Institution or
Ci
rty, Town or Village Glens Falls Street Address Glens Falls Hospital
il frit
Manner of Death n Natural Cause n Accident n Homicide Suicide in Undetermined Pending
01 Circumstances Investigation
Medical Certifier Name Title
Address
`f<{ Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601 2 3
❑X Burial Date Cemetery or Crematory
❑Entombment May 1,2015 St. Alphonsus Cemetery
Address
❑Cremation Pine Street, Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
52 and/or Address
I:: Hold
to
0 Date Point of
NU Transportation Shipment
Q by Common Destination
Carrier
Date Cemetery Address
n Disinterment
Date Cemetery Address
n Renterment
Permit Issued to
Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
f},
407 Ba Road, Queensbur ,NY 12804
Name of Funeral Firm Making Disposition or to Whom
„ Remains are Ship
ped, If Other than Above
rpri Address
.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued LI r 29` ( (5' Registrar of Vital Statistics
W
tr>
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z //
utDate of Disposition 7// J/ f Place of Disposition t_-i e_ Sr X,./eeiJ�--f/ 71,
2 (address)
LIJ
rx (secti lit number) (grave number)
p Name of Sexton or on in Charge of Premises j�U Li C'
Z (please print)
"' /Y1�,2. P/Signature Title
(over)
DOH-1555(02/2004)