Gifford, Sherry NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
'-,'-,:a Name First Middle Last Sex
Sherry R, Gifford Male
Date of Death Age If Veteran of U.S. Armed Forces,
,a -- August 3, 2015 67 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address 41 McCrea Street
Manner of Death m.] Natural Cause ❑ Accident 0 Homicide 0 Suicide ❑ Undetermined ❑ Pending
_ Circumstances Investigation
Medical Certifier Name Title
Michael Fuller, Dr.
'34 Address
East Street Fort Edward, NY 12828
Death Certificate Filed District Numbers it L RegisterJbumber
City, Town or Village Fort Edward cc....11 �� `'� , I
❑Burial Date Cemetery or Crematory
August 5, 2015 Pine View Crematory
❑Entombment Address
ft
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
M and/or Address
Hold
Date Point of
Transportation Shipment
,�°a by Common Destination
° `' Carrier
Disinterment Date Cemetery Address
it:tti El Reinterment Date Cemetery Address
4 - Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
, ` Permission is r by granted to dispose of the human( ns de crib d�b�v dicated.
Date Issued �� Registrar of Vital Statistics
(signat re)
District Number5-15_5 Place V W i� +pit{ ii .
x ^
_* I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
:.; Date of Disposition 08/05/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
-
Name of Sexton or Person in Charge of Premises �.���'
(please print)
Signature Titlelltegi
ftil!
(over)
DOH-1555 (02/2004)