Fairchild, Gilbert NEW YORK STATE DEPARTMENT OF HEALTH ' - ��y
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
' Gilbert F. Fairchild Male
E Date of Death Age If Veteran of U.S. Armed Forces, //
' '`` 09/25/2015 76 War or Dates After 1/31/55 tea/r -2- "/ ((
Place of Death ��G�, Hospital, Institution or 3- $7/ Z.�,,V.,,, ,ram a City, Town or Village Street Address Deceased's Residence
Manner of Death 0 Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
3 Darci Gaiotti-Grubbs,
Address
• } 102 Paork St Glens Falls, NY 12801
,T' Death Certificate Filed � District N tuber Register umber
c
t ,� City, Town or Village �li C 1 &S`t
• ❑Burial Date or Crematory ,o +----
l; 09/28/2015 /4I-e U4_ r�2( iz 'A /d G///�1
{ ,▪ ❑Entombment Address
®Cremation ( V-- am-.f l e/1✓� /�� l�- d
.-Z
w Date Place Removed
" ;❑ Removal and/or Held
and/or Address
• Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
0!• ❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
WI
A.',.= Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
iRemains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human rema" described above ass
t Indic d.
= O ��Date Issued !--oo?46 Registrar of Vital Statistics ✓�-�
(signature)
District Number r5DO /( Place on ar -714:4.1C-zN-
IA
--'1. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 1h-1416- Place of Disposition f:U_ Cr 4Z—.-
", x (address)
'' (section) (lot number( (grave number)
Name of Sexton or Person in Charg of Premises rw '
/f ( ease print)
,,.c , Si nature �" l -"'41�'t
9 Title
(over)
DOH-1555(02/2004)