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Gordon, Gerald 5� YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Records Section ,, ill. Name First Middle Last Sex Gerald J. Gordon Male Date of Death Age If Veteran of U.S.Armed Forces, i' October 5, 2011 55 War or Dates NO 2 Place of Death Hospital,Institution or W City,Town,or Village Glens Falls Street Address Glens Falls Hospital G Manner of Death ®Natural Cause 0 Accident EI Homicide EISuicide 0 Undetermined 0 Pending W Circumstances Investigation U Medical Certifier Name Title W Timothy Murphy Coroner 0 Address 52 Haviland Drive Glens Falls New York 12801 Death Certificate Filed District Number Register Number City,Town or Village 5 60 t L_) 10 ID Burial Date Cemeteryor Crematory 10/11/2011 Pineview Crematorium ❑Entombment Address ®Cremation Quaker Road Queensbury, NY 12804 Date Place Removed 0 Removal and/or Held is and/or Address I' Hold a 0 Date Point of 0 Transportation Shipment d by Common Destination i Carrier Date Cemetery Address 6 0 Disinterment El Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Jilison Funeral Home, Inc. 00885 Address 46 Williams Street, Whitehall, New York 12887 ~ Name of Funeral Firm Making Disposition or to Whom ft Remains are Shipped, If Other than Above W Address 0. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued t c( -/ l 1 } Registrar of Vital Statistics CJ./l,4-`9., (signature) District Number 5 6© ) Place Glens Falls,New York F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition ID II))tt Place of Disposition Pineview Crematorium 2 (address) W th 0 (section) 4Qo,t ,number) f- (grave number) 0 Name of Sexton or Person i Charge of Pre ises ('+5}'� r Ma Et W (Plea Print) 4 Signature / Title at oQ, (over) DOH-1555 (02/2004)