Gibbs Jr., Walter NEW YORK STATE DEPARTMENT OF HEALf-1 ., it g5(0
Vital Records Section Burial - Transit Permit
iin Name First Middle Last Sex
Walter Henry Gibbs, Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
11 /09/2017 83 yrs. War or Dates 1954-1957
f4 Place of Death Town of Hospital, Institution or
City, Town or Village Hague Street Address 239 Decker Hill Road
▪ Manner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
la Circumstances Investigation
ill Medical Certifier Name Title
Kathleen P. Huestis M.D.
Address
P .O. Box 29, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number
nli City, Town or Village Hague 5653
<> 0 Burial Date Cemetery or Crematory
❑Entombment 1 1 /13/201 7 Pine View Crematory
Address
❑X Cremation Queensbury, New York
Date Place Removed
" ❑Removal and/or Held
and/or Address
t— Hold
C3 Date Point of
f ` Transportation Shipment
C by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Alqonkin St. , Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
,'; Address
#r
LU
Permission is hereby granted to dispose of the human remains described above as 'ndicated.
Date Issued 11 /12/201 7 Registrar of Vital Statistics rp_,ctj A _
(signature)
District Number 5653 Place Town of Hague
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
in Date of Disposition (UM I h Place of Disposition et"—, C V�ta ci—'
(address)
EU
VI
CC (section) / (lobnumber) (grave number)
0 Name of Sexton or Person in Charge of Premises � v S ^-� }"
'; /, (pl ase print)
iii
Signature !mot Title IN#AWC
(over)
DOH-1555 (02/2004)