Rounds, Gary r
tt 511
NEW YORK STATE DEPARTMENT OF HEALTH t '' 14
Vital Records Section Burial - Transit Permit
° = Name First Middle Last Sex
Gary P. Rounds Male
Date of Death Age - If Veteran of U.S. Armed Forces,
a= y September 5,2014 72 War or Dates
. Place of Death Hospital, Institution or
2 City, Town or Village Glens Falls Street Address Glens Falls Hospital
W. Manner of Death X Natural Cause [ 'Accident I I Homicide Suicide Undetermined Pending
lAt Circumstances Investigation
ui. ° Medical Certifier Name Title
Paul Bachman
Address
E-E3 HHHN,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number
, City, Town or Village 2
Y 9 Glens Falls 5601 IA
❑Burial Date Cemetery or Crematory
El Entombment September 10, 2014 Pine View Crematory
Address
❑X Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
CO
O Date Point of
yTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
-` Permit Issued to Registration Number
,. :, Name of Funeral Home Alexander-Baker Funeral Home 00037
° , Address
�` 3809 Main Street, Warrensburg, NY 12885
Name of Funeral Firm Making Disposition or to Whom
' Remains are Shipped, If Other than Above
1 Address
WI
A.a
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9 /'I/y Registrar of Vital Statistics Ukj
- (signs re)
District Number 5601 Place Glens Falls 72
1 `_
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition clbiby Place of Disposition F pjJ .j Crty t :,.._
W (address)
U)CL _
(section) (lot number (grave number)
Q Name of Sexton or Person in Charge of Premises r,i�p4l' e441}
Z / (please print)
Signature `�-fy _ 4j._ Title CReintia
Q'� (over)
DOH-1555 (02/2004)