Gifford, James NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
,, Name First Middle Last Sex
James Harwood Gifford Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 2, 2015 79 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address Stanton Nursing &Rehabilitation Center
Manner of Death Rri
iLlj Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Et
lt Suzanne Blood, Dr.
Address
Vt 161 Carey Road Queensbury, NY 12804
Death Certificate Filed District Number Register Number
!iit City, Town or Village
i ®Burial Date Cemetery or Crematory
i May 29, 2015 St. Alphonsus Cemetery
❑Entombment Address
0 Cremation Queensbury,NY 12804
474.-1
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
==l i Transportation Shipment
by Common Destination
Carrier
I, I l Disinterment Date Cemetery Address
14.9
PA
nReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home- SGF 01078
mil Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is h eby granted to dispose of the human r " s dQscrib d ab ve i icated.
3-2—� Date Issued Registrar of Vital Statistics V
a ,..----. i (signnatuure)
District Number 5155 Place J 1tYLL EIL�W U(
fi I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 05/29/2015 Place of Disposition Queensbury,NY 12804
(ad ress)
(secti ) i ton ber) (grave number)
NI Name of Sexto or Person in Charge of Premises !� ' \ l�
(please pint)
Signature Title _MIN Ay-e //
J
(over)
DOH-1555 (02/2004)