Gifford, Eleric (az1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section4114 ^ 4 Burial - Transit Permit
'J" Name First Middle Last Sex
" Eleric Edward Gifford Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 30,2016 86 War or Dates US Army
Place of Death Hospital, Institution or
City, Town or Village Glens Falls,NY
Manner of Death
Street Address Glens Falls Hospital
u_kjNatural Cause Accident ❑Homicide ❑Suicide ❑Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
. M Siddiqui,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Registers N �er
<%r City, Town or Village Glens Falls, NY 5601 ( v'S
� ❑Burial Date Cemetery or Crematory
❑Entombment September 1, 2016 Pine View Crematorium
Address
®Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z ❑Removal and/or Held
P and/or Hold Address
N
0 Date Point of
N E Transportation Shipment
p by Common .Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
`>1: Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury,NY 12804
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 `f 1 f / /A Registrar of Vital Statistics h:C.x` '-k L�
r
(signature
s District Number Jr 6o I Place �� ./.j' C-v \� , �`
F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 9(Z((b Place of Disposition AiL 1t+n.gto-1
2 (address)
W
CO
W (section) `pf: (lot number)St (grave number)
pName of Sexton or Person in Charge of Premises %(�j ^r4 f
Z please print)
W /�/�Signature (.r Title /0 f '77v<
(over)
DOH-1555(02/2004)