Gordon Sr, Daniel NEV3 YORK STATE DEPARTMENT OF HEALTH Burial - Tra$i Permit
Vital Records Section
Name First Middle Last Sex
DANIEL M. GORDON, SR. MALE
Date of Death Age If Veteran of U.S.Armed Forces,
1/20/2014 54 War or Dates
I— Place of Death Hospital, Institution
Z City ,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
W Manner of Death Natural Undetermined Pending
W ® Cause ❑ Accident Li Homicide ❑ Suicide ❑ Circumstances ❑ Investigation
U Medical Certifier Name Title
p DOUGLAS VANDERBROOK M.D.
Address
43 NEW SCOTLAND AVE ALBANY, NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 134
Date Cemetery or Crematory
❑ Burial 1/27/2014 PINE VIEW CREMATORIUM
❑ Entombment Address
® Cremation QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
Q ❑ and/or Address
I— Hold
C
Q Date Point of
d Transportation Shipment
Cl) ❑ By Common
3 Carrier Destination
❑ Date Cemetery Address
Disinterment
111
Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home JILLSON FUNERAL HOME, INC. 00885
Address
46 WILLIAMS ST. WHITEHALL, NY 12887
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
W
4 Permission is hereby granted to dispose of the human remains described above as indicated.
Date 1/21/2014 Registrar of Vital Statistics d1 2-"- C . 3(-.€ €.€- Si.
Issued (signature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition /MIN Place of Disposition ?Jot Lkul efee4 1
w (address)
w
co
cc (section) (lot nu mr) (grave number)
0
D
Z Name of Sexton or Person in Charge of Premises ri) w l NA'
w (please print)
Signature dy)-- Title 02,EIVidt
(over)
DOH-1555 (02/2004)