Hanna, Gordon NEW YORK STATE DEPARTMENT OF HEALTH
(1(2
Vital Records Section
Burial - ran tit Permit
Name First Middle Last Sex
Gordon Floyd Hanna Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 26, 2016 90 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X❑ Natural Cause illAccident ❑ Homicide ❑ Suicide ❑ Undetermined El❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
Shamid Ahmed, Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5 I 1,5
❑Burial Date Cemetery or Crematory
March 29, 2016 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
E Hold
0 Date Point of
❑Transportation Shipment
II by Common Destination
a Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home-Argyle 01077
Address
123 Main St., Argyle NY 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3 J 'Z.`i , > Registrar of Vital Statistics (j3Cvvtv-e .�
(signature)
District Number CSC. i Place C (sin S \ Os Al
li'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 03/29/2016 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
W.
(section) (lot num r) (grave number)
Name of Sexton or Person in Charge of Premises G ttit 3tiNj�'
/�j (please print)
LU Signature �'` TitleIke-Milt
(over)
DOH-1555 (02/2004)