Gilson, Leo 1. a
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Leo Gilson Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/16/2018 88 Years War or Dates 1950-1953
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
Manner of Death Natural Cause ❑Accident ❑Homicide El Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Gwendolyn Morris-Dickinson PA
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 588
®Burial Date Cemetery or Crematory
12/22/2018 Pine View Cemetery
Entombment�.. Address
,❑Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
• ❑Transportation Shipment
by Common Destination
• Carrier
❑Disinterment Date Cemetery Address
❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/18/2018 Registrar of Vital Statistics RobertA Curtis(E(ectronica((ySigned)
(signature)
District Number Place
5601 Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 1 2/2 2/2 0 Mice of Disposition Pine View Cemc E Quccnsbury
M(seccttio) (lot number)W k n �(grave number)
• Name of Se n or Person in Charge of Premises Conn iP T,- GnPdPrt
(please print)
Signature MU'
Q Title Cemetery Superintendent
(over)
DOH-1555(02/2004)