Gazel, Edward NEW YORK STATE DEPARTMENT OF HEALTH * . 1 .tt ill L
Vital Records Section Burial -Transit Permit
Name First Middle Last Sex
Edward F. Gaze! Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 15, 2015 62 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Cr Manner of Death 0 Natural Cause E1 Accident El Homicide D Suicide riUndetermined ri Pending
10
U Circumstances Investigation
W, Medical Certifier Name Title
Joseph C. Mihindu, MD,
Address
20 Murray Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 5601 2...1 e-+
❑Burial Date Cemetery or Crematory
April 20, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date ' Place Removed
z Removal and/or Held
and/or Address
Hold
sti Date Point of
Transportation Shipment
y by Common Destination
a Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Z; 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
X Address
tit
1 .: Permission is hereby granted to dispose of the human remains described above as,indicated.
Date Issued 1 f as I lc Registrar of Vital Statistics W CA -�--kit), vk-c '
-'04 (signature)
District Number 5601 Place E( S TQA A , y
4
i F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 04/20/2015 Place of Disposition Quaker Road Queensbury,NY 12804
Z' (address)
w
rt (section) A(lot number) (grave number)
lv
P Name of Sexton or Person in Ch rge of Premises AN z .
( lease print)
Signature Title +Ft
(over)
DOH-1555 (02/2004)