Gordon, Bernard Morris #606
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records s
Name First Middle Last Sex
Bernard Morris Gordon Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/06/2020 78 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 5 Treasures Place, Queensbury Town, New York 12804
C) Manner of Death Natural Cause Accident 1:1Homicide Suicide Undetermined Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
0 David Cunningham MD
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 102
Burial Date Cemetery,Crematory or Facility Name
05/12/2020 Pine View Crematory
Entombment Address
I^1 Cremation Queensbury Town,New York
Donation
0 Removal Date Place Removed
and/or -7 and/or Held
H N Hold Address
O
ia. Date Point of
—7—
OF Transportation
U) by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
f.. Remains are Shipped,If Other than Above
Address
M
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/12/2020 Registrar of Vital Statistics Carntinexfegarde Bar6er�-YectromcalySrgned�
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
WDate of Disposition s-/3-�2t� Place of Disposition /��rJ� e- C�kela
X. (add ss)
W
N (section) (lot number) (grave number)
Name of Sexton or Per i Char a of Premi s t^ rlrn'� �`'�
(please print/z
Uj Signature Title g !!z `�
DOH-1555(07/18)A 1 of 2
Public Health Law Sec. 4145(2b) 013792
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#