Gordon, Paul NEW YORK STATE DEPARTMENT OF HEALTH I. i ri /1g
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Paul N. Gordon Male
Date of Death Age If Veteran of U.S.Armed Forces,
I. December 13, 2017 91 War or Dates World War II
2 Place of Death Hospital, Institution or
W City,Town,or Village Whitehall Street Address Home
a Manner of Death iXptlatural Cause El Accident n Homicide El Suicide I I Undetermined n Pending
W Circumstances Investigation
U Medical Certifier Name Title
W H Peter Dierksen MD
Q Address
275 Route 30 N Bomoseen Vermont 05732
Death Certificate Filed District Number rue
(Y Register Number 7
City,Town or Village Whitehall5
❑Burial Date Cemetery or Crematory
December 18, 2017 Pineview Crematorium
❑Entombment Address
0 Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
4 0 Removal and/or Held
- and/or Address
le Hold
0 Date Point of
4 n Transportation Shipment
d by Common Destination
Carrier
= Date Cemetery Address
0 El Disinterment
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
I- Name of Funeral Firm Making Disposition or to Whom
x
rr Remains are Shipped, If Other than Above
W Address
CL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued / c 1 1 to) O 17 Registrar of Vital Statistics c ,\ALLQ Q •
(signature)
District Number 5 9(P LP Place Whitehall,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 12/18/2017 Place of Disposition Pineview Crematorium
2 (address)
til
it
0 (section) (lot number` ,,} (grave number)
W Name of Sexton or Person in Charge of Premi s aril— ✓, vi
W j (phase print)
Signature r Title arliA ll-a^yam
(over)
DOH-1555 (02/2004)