Katz, Gordon /t 3iL
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gordon Garner Katz Male
Date of Death Age If Veteran of U.S. Armed Forces,
j / 8 / 71)16 63 War or Dates
14 Place of Death Hospital, Institution or
ZCity, Town or Village Wilton Street Address 683 Saratoga Road
0 Manner of Death"Natural Cause 0 Accident 0 Homicide RI Suicide riUndetermined Pending
Iti
Circumstances Investigation
la Medical Certifier Name Title
DAI4 e-c. G OHO C( ^192
Address ,_
Death Certificate Filed District Number Register,Nu tuber
City,Town or Village Wilton j/
`` ElBurial Date Cemetery or Crematory
I / IZ/ 2O)t, Pine View Crematory
0 Entombment Address
;` ; Cremation Queensbury, NY (LZd f
Date Place Removed
❑Removal and/or Held
and/or Address
itHold
VD Date Point of
O'0 Transportation Shipment
13 by Common Destination
Carrier
im
>< Q Disinterment Date Cemetery Address
iiiiilli
Q Reinterment Date Cemetery Address
iiiiijiiti Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care, Inc 00364
Address
402 Maple Ave., Saratoga Springs, NY 12866
iit
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Mi Address
Ll
111
N. Permission is hereby granted to dispose of the human remains described above as indicated.
':_ Date Issued ///// 1/9 Registrar of Vital Statistics / / Vf/7
(sIgnatur
>'« District Number /5//7- Place Wilton , New York
'* I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ili Date of Disposition 1/410, Place of Disposition 'jru/U/w Grano or --
2 'S (address)
0
c (section) d (lot numbr) (grave number)
0 Name of Sexton or Person in Char of Premises - CYST . twWtt
2 /� 4Yp_lease print)
ILI Signature `� WC[r Title
(over)
DOH-1555 (02/2004)