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Gibbs, John 02/07/2006 07:33 85184945160 c jMINDY CONWAY PAGE 01/01 NEW YORK STATE DEPARTMENT OF HEALTH T 5T) Vital Records Section Burial - 1 ransit Permit AMMO, AMY ,4' Name First Middle Last Sex rfr. John _ E. Gibbs Male 3 Date of Death Age If Veteran of U.S. Armed Forces, f •� July 23,2017 58 _ War or Dates 1 Place of Death Hospital, Institution or City, Town or Village Chester Street Address 111 Dell Culver Rd. Manner of Death❑Natural Cause Q Accident []Homicide Ei Suicide II Undetermined r" Pending Circumstances Investigation , Medical Certifier Name Title William Orluk . Address __ f Chester Health Center,Chestertown,NY 12817 Death C irate Filed District Number Register Number _ City, ow r Village C j E- it .- 5405 R ILI 0 Burial Date Cemetery or Crematory August 7,2017. Pine View Crematory Entombment Address It Cremation _ 21 Quaker Rd., Queenebury,NY 12804 Date Place Removed O Removal and/or Held and/or Address H Hold O _ Date Point of O.• Transportation _ Shipment _ © by Common Destination Carrier _ _ • Disinterment Date Cemetery Address ❑Renterment Date Cemetery Address .-" Permit Issued to Registration Number Name of Funeral Home Alexander-Baker Funeral Home 00037 ;,:k Address p3809Main Street,Warrensburg,NY 1.2885 -r Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above _ Address • f: Permission is here y granted to dispose of the human remain(nd�escribed above as indicated. Date issued qji as 1 Registrar of Vital Statistics _______ f� ignature) p:;_ District Number �5a. Place a-' O4' iines� t`.,r^ I certify that the remains of the decedent identified above were disposed of in�accordance �with this permit on: w Date of Disposition g I g Lf1 Place of Disposition 1`+lxq 4As Lr or--, ,E (address) w a (sectlpn) 01 number) l (grave number) O• Name of Sexton or Person in Charge of Pre ises L Ante' J soAlt W (pte e Print) Signature Title — ter£i 1 N (over) DOH-1555(02/2004)