Garlick, Gordon s ;.
NEW YORK STATE DEPARTMENT OF HEALTH Vital F�ecords Section Burial - Transit Permit
r: Name First Middle Last Sex
:rjJ Gordon K. Garlick Male
g; Date of Death Age If Veteran of U.S. Armed Forces,
,.� December 3, 2014 87 War or Dates
1°�° Place of Death Hospital, Institution or
" City, Town or Village Saratoga Springs Street Address 35 New Street
° Manner of Death Ix]Natural Cause Accident I (Homicide Suicide 'Undetermined Pending
Circumstances Investigation
la Medical Certifier Name Title
IA Suzanne Blood,MD
Address
::: 161 Carey Rd.,Queensbury,NY 12804
-... Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs,NY LI S>p1 s 39
❑Burial Date Cemetery or Crematory
12/5/14 Pine View Crematory
❑Entombment Address
II Cremation 51 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
r: Hold
Cl) Date Point of
NI Transportation Shipment
Q by Common Destination
Carrier
Disinterment Date ' Cemetery Address
(i Reinterment
Date Cemetery Address
Permit Issued to Registration Number
• Name of Funeral Home Regan Denny Stafford Funeral Home 01443
• Address
:!'g: 53 Quaker Road,Queensbury,NY 12804
' :: Name of Funeral Firm Making Disposition or to Whom
iiii, Remains are Shipped, If Other than Above
I
_Address
" : Permission is her by granted to dispose of the human remains scri d ov i ' ated.
. Registrar of Vital Statistics
Date Issued �Z '� � 9�
(signature)
y,:.l: District Number t l � 1 Place Saratoga Springs,NY
}_ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition tZkill Place of Disposition Zits. C ofL.%
2 (address)
W
co
0 (section) - (lot num ) (grave number)
Q Name of Sexton or Person ' Charge of Premises it,
Z (please print)
uJ
Signature nature `�'" Title CulArritAiti
(over)
DOH-1555(02/2004)