Gillman, Daniel 71 011
NEW YORK STATE DEPARTMENT OF HEALTH Burial - TransitPermit
Vital Records Section
14. Name First Middle Last Sex
;. : Daniel James Gillman Male
Date of Death Age If Veteran of U.S. Armed Forces,
f Se s tember 12 2015 54 War or Dates n/a
Place of Death Hospital, Institution or
City, Town or Village Lake George Street Address 304 Lockhart Mountain Road
.r. Manner of Death X Natural Cause [ I Accident Homicide Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
r Darci Gaiotti-Grubbs Dr.
Address
f 1 102 Park St, Glens Falls,NY 12801
:er Death Certificate Filed District Number RegisterN umber
:;_ City, Town or Village Queensbury, NY 5657 ,.�(
El Burial Date Cemetery or Crematory
CI Entombment September 14, 2015 Pine View Crematorium
Address
CI Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
1:: Hold
N
0 Date Point of
N Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
f Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
,* Address
407 Bay Road, Queensbury, NY 12804
';;;;Pe 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 r 'ns describe. • • s ind' ated.
Date Issued el-lc- e90 i. Registrar of Vital Statistics D I
fr (signature)
{
rrf �j(,District Number Zgl Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of!in accordance with this permit on:
g2 Date of Disposition 9 1 l icjic Place of Disposition 4?,JL, (r or-
(address)
Ir
(section) a,,y(lot number} 'V y (grave number)
Q Name of Sexton or Person in Char a of Premises �,.Z ( ase print)
W
Signature Title Yt
(over)
DOH-1555(02/2004)