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Rich, Gorman . . # 2 1,0 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Gorman Harlan Rich Male Date of Death Age If Veteran of U.S.Armed Forces, 03/24/2018 86 Years War or Oates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death©Natural Cause El Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation Medical Certifier Name Title Marvin Davidowitz MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 154 ❑Burial • Date Cemetery or Crematory 03/27/2018 Pine View Crematory j ❑Entombment Address �Cremation Queensbury Town, New York Date Place Removed M1❑Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier ❑Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to Registration Number • Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 fi 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 03/27/2018 - Registrar of Vital Statistics Mien A Curtis(rEkctronicallySigne (signature) District Number 5601 Place Glens Falls, New York x I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: h Date of Disposition (IA lit Place of Disposition (address) (section) gilt number) (grave number) Name of Sexton or Person in Charge of Pr misesaJ �✓'f (plea print) Signature ri' Title ICCIAMUtt- (over) DOH-1555 (02/2004)