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Gordon, William 1/NEW YORK STATE DEPARTMENT OF HEALTH 416 Vital Records Section t Burial - Transit Permit _= Name First Middle Last ' Sex tr William H. Gordon Male : ' Date of Death Age If Veteran of U.S. Armed Forces, zpx.$f.* October 9,2014 66 War or Dates NA Place of Death Hospital, Institution or 14 City, Town or Village Lake George Street Address 779 Diamond Point Road ta Manner of Death Undetermined Pending Natural Cause Accident � �Homicide ]Suicide Ja Circumstances Investigation U. b Medical Certifier Name Title __ Paul Bachman MD : Address 3767 Main Street,HHHN,Warrensburg,NY 12885 Death Certificate Filed District Number Register Number : City, Town or Village Lake George 5651 }D CI Burial Date Cemetery or Crematory October 13,2014 Pine View Crematory ❑Entombment Address ©Cremation 21 Quaker Rd., Queensbury,NY 12804 Date Place Removed Z I I Removal and/or Held O and/or Address F- Hold co 0 Date Point of w —Transportation Shipment 'p by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address x Permit Issued to Registration Number :j Name of Funeral Home Alexander-Baker Funeral Home 00037 ;„ Address $$ex 3809 Main Street,Warrensburg,NY 12885 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address 10_ PA Permission is hereby granted to dispose of the human remains described above s i dicated. y:me. Date Issued 10-10-14 Registrar of Vital Statistics . ature) me;; District Number 5(i El Place Lake George,NY I certify that the remains of the decedent identified above w disposed of in ac dance with this permit on: ~ �� Z f W Date of Disposition j(�'/f�"-/ Place of Disposition /�ii K� 4fA ey 2 (address) W co (section) :/..„4 (numb r) (grave number) pName of Sexton or P so rge of emises � + W Signature Title C40 ¢6 r :z A. ` (over) DOH-1555(02/2004)