Gilbert, Jr. Wilbur -tr. qq3
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NEW YORK STATE DEPARTMENT OF HEALTH ,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex Male
Wilbur R. Gilbert, Jr.
,
Date of 1 Age ' If Veteran of U.S. Armed Forces.
Mi - 80 War or Dates Korean
Place of Death Hospital, Institution or
City.Vi901.01/XFAN Glens Falls . Street Address Glens Falls Hospital
A Manner of Death l'
.--
IX!Natural Cause 0 Accident Ej Homicide 0 Suicide
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Daniel Way MD Title Undetermined 0 Pending
"-'Circumstances Investigation
Medical Certifier Name
.,,..
-.1P1 Address
1 Glens Falls, NY
Death Certificate Filed District Number Regiej.I cp-iber
0 City, TONOCXXvinge Glens Falls i 5601
Date i Cemetery or Crematory
- LJ Burial , 10/5/2011 1 Pine View Crematory
I Address
Cremation i Queensbury,NY
. ) Date ! Place Removed
Q2 ri Removal
I-1 and/or Held
. and/or Address
gt Hold
0 ; Date i Point of
tit 0 Transportation i ; Shipment
4 by Common Destination
Carrier
Date i Cemetery Address
:;i:: Disinterment
Date 1 Cemetery Address
Reinterment ,
q Permit Issued to Registration Number
X,3 Name of Funeral Home Brewer Funeral Home, Inc. ! 00211
igq Address
24 Church St., Lake Luzeme,NY 12846
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
If
Permission is hereby granted to dispose of the human remains d c .1) d a ve icated.
Ag
-.A Date Issued /0/0...S/20// Registrar of Vital Statistics
ft (signature)
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District Number ;',.:360/ Place /4-4:/ 7217 A7
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i,....:
6. Date of Disposition /040-4011 Place of Disposition ?inet.;i:ec.,J Cr<YY-Ici.jort .*,*1.-v\
(address)
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in Signature Premises (section)yA., i ,--1 (lot number)
y 1NsurNCII (grave number)
Name of Sexton or Personin Charge of ,
Z (please print) ,
W ix.4444.4l.4.4.4,... Title • . •
S.,ICIS.1- ,—.-.114;
DOH-1555 (10/89) p. 1 of 2 VS-61