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Gibson, Robert James NEW YORKSTATE DEPARTMENT OF HEALTH J1 Bureau of Vital Records Burial - Transit Permit 1 Name First Middle Last Sex Robert James Gibson Male Date of Death Age If Veteran of U.S.Armed Forces, 03/30/2020 70 Years War or Dates 1971-1972 F.. Place of Death Hospital,Institution or WCity,Town or Village Guilderland Town Street Address The Grand at Guilderland p Manner of Death W © Natural Cause Accident El Homicide Suicide Undetermined Pending Circumstances Investigation G Medical Certifier Name Title Jonathan Waldman MD Address 127 Main St,Guilderland Town,New York 12085 Death Certificate Filed District Number Register Number City,Town or Villa a Guilderland 0155 gg Burial Date Cemetery,Crematory or Facility Name 04/03/2020 Pine View Crematory Entombment Address 0 Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held N Hold Address O IL Date Point of N ❑Transportation by Common Shipment Carrier Destination 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 i•• Remains are Shipped,If Other than Above Address ft W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/03/2020 Registrar of Vital Statistics Lynne Buchanan(ECectronicalTy Signer /signature/ District Number 0155 Place Guilderland, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 3 ZD Place of Disposition JL ZA0 r, LU (address/ W IX (section) (rot number) (grave number) SName of Sexton or Person in Charge of Premises (114�1 1, S,LIAIJ8 Z (plase print/ W Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 013498 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#