Bates, Gary I ' 1 3S
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Pe mit
`;`. Name First Middle Last Sex
Gary R. Bates Male
: Date of Death Age If Veteran of U.S. Armed Forces,
• , May 17,2018 80 War or Dates Korean
:,; ; Place of Death Hospital, Institution or
MI City, Town or Village Warrensburg Street Address 3679 Main St.
Wl
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
" Circumstances Investigation
m, Medical Certifier Name Title
4_, Anthony Petracca Jr.
Address
. ;3 Iron Gate Center,Glens Falls,NY 12801
, Death Certificate Filed District Number Register Number
:` City, Town or Village Warrensburg 5660
❑Burial Date Cemetery or Crematory
May 21,2018 Pine View Crematory
0 Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
V)
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
=,v± Permit Issued to Registration Number
%2 Name of Funeral Home Alexander-Baker Funeral Home 00037
- Address
3809 Main Street,Warrensburg,NY 12885
M1 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 hu remains eScribed above as indicated.
Date Issued Registrar of Vital Statists - -.— _J
(signature)
... District Number 5660 Place Warrensburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition h t i I i$ Place of Disposition F.4,1)-• 4,t---
W (address)
co
ce (section) /A` (lot numb (grave number)
Q Name of Sexton or Person in Charge of Pre ises IAA4..
Z (p ase pTlfit)
W /�
Signature /mot Title
(over)
DOH-1555 (02/2004)