Hayes, Gary NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gary L. Hayes Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 07, 2011 75 yrs. War or Dates ' 54- ' 58
I- Place of Death Hospital, Institution or
ZCity, Town or Village Kingsbury Street Address 21 9 Green Barn Rd.
a Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending
Circumstances Investigation
la Medical Certifier Name Title
c M ON{A/ SToure7VB '(. 1'I 0
Address � /���/
/o.? al:mks'n., G-,[ -ws FRI LS N
Death Certificate Filed District Number Register Number
City, Town or Village Kingsbury 5'7 Lo - g
❑Burial Date Cemetery or Crematory
DEntombment May 09, 2.01 1 PineView Crematorium _ _
Address
®Cremation Town of nueensbury, NY.
Date Place Removed
Z Removal and/or Held
9 ❑and/or Address�
t Hold
0 Date Point of
Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01 1 36
Address
PO. Box 277, Fort Ann, NY. 12827
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
t
tatf
II` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 5/0 9/1 1 Registrar of Vital Statistics 1.- /1)a ,..,
1-, (signature)
District Number 574,-:2, Place Town of Kingsbury, NY.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k /
It Date of Disposition c"tip„it Place of Disposition Pint UiC1J Cc1"cl'or,u _
2 (address)
UI
CA
IM (section) _ (lot number) (grave number)
ci Name of Sexton or Per 9n in Charge f Premises t'r,st i� CI If
r / y ( lease print)
Signature ILI L //7J Title (2 t MA TCt_
(over)
DOH-1555 (02/2004)