Gilbert, Richard f 9
NEW YORK STATE DEPARTMENT OF HEALTH S3
Vital Records Section Burial - Transit Permit
a Name First Middle Last Sex
Richard T. Gilbert Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 17,2014 71 War or Dates
Place of Death Hospital, Institution or
City, Town or Village T/O Bolton Street Address 908 E. Schroon River Road
o: Manner of Death n Natural Cause Accident Homicide Suicide Undetermined Pending
r" Circumstances Investigation
.. Medical Certifier Name Title
Joseph C.Mihindu
Address
20 Murray Street,Glens Falls,NY 12801
pz-
s' Death Certificate Filed District Number Register Number
;' City, Town or Village Bolton 5650
❑Burial Date Cemetery or Crematory
January 21,2014 Pine View Crematory
Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
O Date Point of
Q. n Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
>: Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
m§z: 3809 Main Street,Warrensbur_,NY 12885 _
a Name of Funeral Firm Making Disposition or to Whom
g_, Remains are Shipped, If Other than Above
Address
Permission is ere y granted to dispose of the human remains des ribed above as indicated.
Date Issued 4 Registrar of Vital Statistics /mt.,-
Cov,m,Jec
` (signature) v
*a. District Number 5650 Place Bolton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition (/. v 1pi Place of Disposition ?nt Orro Cvn-ctru,✓�
W (address)
W
p0 (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises Ghr,—s ,( 3ln,q
Z (ease print)
W �,nSignature dfL ./ Title COE-01 p*
(over)
DOH-1555(02/2004)