Angus, Gordon NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Pe it
Name First Middle Last Sex
Gordon Warner Angus Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 26, 2016 80 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death ElNatural Cause 0 Accident ❑ Homicide ❑ Suicide ❑ Undetermined El Pending
Circumstances Investigation
W Medical Certifier Name Title
G Michael Miles,
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number .��/ Registe�Der
City, Town or Village Glens Falls ll��cc��
❑Burial Date Cemetery or Crematory
September 27, 2016 Pine View Crematory
D Entombment
- --- Address— ---- -
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
0 Date Point of
a ❑Transportation Shipment
by Common Destination
0 Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
2 Address
CC
- Permission is hereby ranted to dispose of-he human r€mains Bribed a yeas kW'
Date Issued c Registrar of Vital Statistics /
(signature)
District Numbe ( .1 ' Place ,A 3A `--77
1... I certify that the remains of the decedent identified above were disposed of in acc rdance with this permit on:
w Date of Disposition 09/27/2016 Place of Disposition Quaker Road Queensbury,NY 12804
E (address)
W
07
(section) � (lot number) (grave number)
0 Name of Sexton or Person in Charge o Premises C- tr,s r' �t'��
z please print)
W Signature 4( Title ( f KIA_
(over)
DOH-1555 (02/2004)