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Rhodes, Gordon NEW YORK STATE DEPARTMENT OF HEALTH it Mg Vital Records Section Burial - Transit Permit ',`'r rre: Name First Middle Last Sex 'rrr, Gordon W Rhodes Male fr: Date of Death Age If Veteran of U.S. Armed Forces, :' February 27, 2015 89 War or Dates le.e Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death IX!Natural Cause Accident L I Homicide Suicide Undetermined Pending Circumstances Investigation Medical Certifier Name Title Sean Bain,MD 'r' Address 100 Park St. Glens Falls,NY 12801 Death Certificate Filed District Number Register Number ::r S City, Town or Village Glens Falls 5601 lA ❑Burial Date Cemetery or Crematory ❑Entombment March 3, 2015 Pine View Crematorium Address ❑x Cremation Quaker Road, Queensbury, NY 12804 Date Place Removed Z Removal and/or Held and/or Address ' Hold N © Date Point of wTransportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address 4.*1 Permit Issued to Registration Number s• Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker 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,ps indicated. ., Date Issued 13/1> Registrar of Vital Statistics V- C-V& -. :::r (signatur `:::' District Number 5601 Place Glens Falls) 6V y I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ZleIli Date of Disposition /S) t Place of Disposition Of iv L (address) W U) o (section) //` ,(lot numb ) (grave number) Q Name of Sexton or Person in Charge of Premises U'1ni 3ti. 1' W Z / please print) Signature j .- Title 44.0ti i! (over) DOH-1555(02/2004)