Gilligan, Sr. Royce NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Tran it Permit
Name First Middle Last Sex
Royce R Gilligan,Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 5,2012 79 War or Dates
. Place of Death Hospital, Institution or
Z City, Town or Village Town of Moreau I Street Address 39 Fawn Rd.
tii
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
US Circumstances Investigation
w Medical Certifier Name Title
Dr.Michael Adams,MD
Address
South Glens Falls,NY
a, Death Certificate Filed District Number Register Number
g.. City, Town or Village Town of Moreau.NY 45 6,2. //
❑Burial Date Cemetery or Crematory
June 7, 2012 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
1::: Hold
N
O Date Point of
u) Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
a. Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls, NY 12803
Name of Funeral Firm Making Disposition or to Whom
l' Remains are Shipped, If Other than Above
E Address
It
,w
Permission is hereby granted to dispose of the human remains escribed above as ' dicated.
, Date Issued �f//Z-- Registrar of Vital Statistics
/ ( ignature)
:-: District Number 4 562; Place Town of Moreau.NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z DispositionPlace of Disposition C W Date of (, i2NUL�w o fbu..
W (address)
Cl)
O (section) ` [ (lot number) (grave number)
QName of Sexton or Person in Charge of remises nr,S+ S[N.rit-
Z (please print)
W
Signature Title COX pn'rai.,
(over)
DOH-1555(02/2004)