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Gannon, Terry NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section d 4 Burial - Transit ermit Name First Middl-.°' Last Sex Terry Donald annon Male Date of Death Age If Vet- - • U.S. Armed Forces, December 7, 2016 49 War or Dates I'— Place of Death Hospital, Institution or W City, Town or Village Saratoga Springs Street Address Saratoga Hospital CI Manner of Death ❑ Natural Cause cLIIIcident ❑ Homicide ❑ Suicide 0 Undetermined ❑ Pending C3. Circumstances Investigation W Medical Certifier Nme., Title CI Sicc- v 0 Addres r qOt Or Death Certificate Filed t�J District Number Register Number City, Town or Village ��u l 571 ❑Burial Date Cemetery or Crematory December 12, 2016 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held • and/or Address E Hold Pine View Crematorium Date Point of a ❑Transportation Shipment i Cl) by Common Destination 5 Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom I Remains are Shipped, If Other than Above • Address IX' W. EL Permission is hereby granted to dispose of the human rematcTes ri d abor ndicate Date Issued 12I12_\Qb ,p Registrar of Vital Statistics (signature) District Number 1-. 50i Place 0, e r1 w^CA pS - I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: uji Date of Disposition 12/12/2016 Place of Disposition Quaker Road Queensbury,NY 12804 24 (address) LU co t' (section) ,,(lot number) (grave number) ea / Name of Sexton or Person in Charge of Premises <i rl ir- s cii 4itt (ple se pant) L11. Signature e Title ( lr' ratt (over) DOH-1555 (02/2004)