Gobeille, Jr. Ernest NEW YORK STATE DEPARTMENT OF HEALTH ft I
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ernest P. Gobeille,Jr Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 2, 2012 76 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 3 Woodcrest Drive
• Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W, Medical Certifier Name Title
G1 John Sawyer,MD
Address
Queensbury,NY
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury,New York 5657
❑Burial Date Cemetery or Crematory
January 9,2012 Pine View Crematory
❑Entombment Address
L1 Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
Hold
O Date Point of
• Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton-Healy Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
II.-: Remains are Shipped, If Other than Above
2 Address
Permission is hereby granted to dispose of the human runs described above s indicated.Date Issued 1 , lckcD, Registrar of Vital Statistics
(signature)
District Number 5657 Place Queensbury,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 110-It Place of Disposition i�UJ�
ta.) C('o/s orfu,
W (address)
CO
(section) (lot number)` (grave number)
QName of Sexton or Per n in Charge f Premises I co-tcpkc Jehvrt-
Z (please print)
W L
Signature T Title
(over)
DOH-1555(02/2004)