Nolan, Sr. Gary NEW YORK STATE DEPARTMENT OF HEALTH- w 1 ,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gary Thomas Nolan Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
01 /1 9/2 01 1 61 War or Dates
I_- Place of Death Hospital, Institutio or
Argyle Peasant Valley Health Center
City, Town or Village Street Address
ILI
• Manner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide riUndetermined ri Pending
at
Circumstances Investigation
iii Medical Certifier Name Title
O Edit Masaba M.D.
Ad1ir1is4 State Route 29 Greenwich,NY 12834
Death Certificate Filed Argyle District Number 4.-- _I Register Number
City, Town or Village J , 5�
❑Burial Date Cemetery or Crematory
January 21 ,2011 Pine View Crematory
[]Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
E ❑and/or Address
C. Hold
07
0 Date Point of
tt 0 Transportation Shipment
O by Common Destination
Carrier
(0 Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to MB Kilmer Funeral Home Re stratin Number
Name of Funeral Home
Address
123 Main St. Argyle,NY 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
fr
f3 Permission is hereby granted to dispose of the human re 11 rns describ d a e indicated.
Date Issued Q /a (( o)I Registrar of Vital Statistic !ta/(,(a
(signa ure�7 )
District Number S 7 5 C) Place /b n 6 1 //Y .Y'L_
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
p (Place of Disposition P `Date of Dis osition �; p 2'�I ZOi P ,nt w./ Cirm,cf-Otiv,,
2 (address)
11
tO
C (section) L(lot number (grave number)
cr
O? Name of Sexton or Person in Charge o remises h t �UQI T - mot'"K
1 (please print)
Signature 7!1-i-ori, .� Title C¢�ih>}FOf.
(over)
DOH-1555 (02/2004)