Gates,Terry D. NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Terry D.Gates Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/10/2020 78 Years War or Dates
Place of Death Hospital,Institution or
City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
Mannerof Death F)KI Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
John Quaresima MD
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City,Town or Village Fort Edward 5755 46
❑Burial Date Cemetery,Crematory or Facility Name
05/12/2020 Pine View Crematory
Entombment Address
X❑Cremation Queensbury,New York
Donation
Z Removal Date Place Removed
Fand/or and/or Held
N Hold Address
N ❑Transportation Date Point of
b by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
1FIReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
1L Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/12/2020 Registrar of Vital Statistics gimeeMaltoney(_-kctronicatySoneq)
(signature)
District Number 5755 Place Fort Edward, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition S 113)U Place of Disposition
(address/
t
it
(section) (lot numbed (grave number/
A-1
Name of Sexton or Person in Charge of Prem' es a
lease printl/�
Signature Title
DOH-1555(o7/18)p 1 of 2
J
Public Health Law Sec. 4145(2b) 013 7
Receipt
Human remains of delivered on , 20—
Pine View Cemetery Representing the Tuneral home named on burial permit
Official Funeral Directors Reg.or License#