Valencia, Gabriel L
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gabriel Fernando Valencia Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 17, 2017 65 War or Dates
F., Place of Death Hospital, Institution or
Z City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
• Manner of Death ❑X Natural Cause Accident —Homicide pi Suicide Undetermined 1-1 Pending
W Circumstances Investigation
W Medical Certifier Name Title
• M Siddiqui,MD
Address
Fort Edward,New York
Death Certificate Filed District Number Regist�r UNumber
City, Town or Village Fort Edward,New York 5755
❑x Burial Date Cemetery or Crematory
March 22, 2017 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
Hold
CO
O Date Point of
yn Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
• Address
LL'
W
0. Permission is hereby granted to dispose of the humary: ins described a o e s ' dicated.
Date Issued 3 a0- Registrar of Vital Statistics
.$
District Number 5ci Place lo
edisijiaturd)
I certify that the remains of the decedent identified above were d'sposed of in accord nce with this permit on:
Z �/
W Date of Disposition 2 / o/fPlace of Disposition 2/ Zr'CLt 2
2 (address)
LLI
O (section) 4 (lot numb r) (grave number)
p Name of Sextoj Person in Charge of Premises �G/1�'iUi� L. � def-e,
Z I ` ase print)
Signature ' 2 Title CE1!u
G J -fir
(over)
DOH-1555(02/2004)