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Reed Jr, Gordon NEW YORK STATE DEPARTMENT OF HEALTH' x / • Vital Records Section Burial - Transit Permit Name First Middle Last Sex Gordon Miller Reed Jr. Male Ai Date of Death Age If Veteran of U.S. Armed Forces, December 7, 2016 77 War or Dates Place of Death Hospital, Institution or City, Town or Village Moreau Street Address 17 Washington Road • Manner of Death X❑Natural Cause 0 Accident ❑ Homicide 0 Suicide Undetermined El 1-1 Pending CircumstancesInvestigation Medical Certifier Name Title Atilla Kayalar, Address 6 Hearts Way Queensbury, NY 12804 Death Certificate Filed District Number Register Number -I City, Town or Village Moreau 9 U of A 0 Burial Date Cemetery or Crematory December 12, 2016 Pine View Crematory P ,0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed Removal and/or Held and/or Address Hold tij Date Point of ix.':❑Transportation • Shipment . 0 by Common Destination Carrier A-: Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078 Address 136 Main Street, South Glens Falls NY 12803 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address r L4 Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued / Z/l//c Registrar of Vital Statistics ,e7/7 4 Y (,el-.�(•-� -: (signature) District Number (./5C Place 7?6C ri at /o)rCe 6e- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ut Date of Disposition 12/12/2016 Place of Disposition Quaker Road Queensbury,NY 12804 X (address) (section) /r (lot number) (grave number) Name of Sexton or Person in Charge of Pr mises t r,rtp � t4qi@. / se print) W Signature Title (PiAr-1"1P44- (over) DOH-1555 (02/2004)