Gilmour, Francis t t -4.gg
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Francis Landy Patton Gilmour Male
Date of Death Age If Veteran of U.S. Armed Forces,
02/16/7013 76 years War or Dates
j- P of Death Hospital, Institution or
Ci ow AAA/il XX Glens Falls Street Address Park St Glens Falls N Y
-of Death[Vffatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending
Uj Circumstances Investigation
in Medical Certifier Name Title
Cl
Darci A Gaiotti-gru ubhc M D
Address
102 Park St Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
L6it TowstftyiIXX Glens Falls 5601 72
❑Burial Date Cemetery or Crematory
❑Entombment 02/20/7013 Pine View Cemetery
Address
0Cyemation Queensbury, NY 12804
/ Date Place Removed
Removal and/or Held
and/or
to Hold Address
f
0 Date Point of
tik❑Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
;: Address
11 Lafayette Street Queensbury. N Y 12804
s Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
0
A,.111
Permission is hereby granted to dispose of the human emains described bove as i dica9d.
Date Issued 02/20/2013 Registrar of Vital StatisticsZ ,� -
(signature)
District Number Place
5601 Glens Falls / PSI/
; ::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
I Date of Disposition L-V-(2, Place of Disposition 0 rt.J f�.wwcter'aok;,
(address)
tii
I (section) /II `(lot number) (grave number)
ta Name of Sexton or Person in Charge f Premises t n.JA ►L- .Si+rlt-
,/�
AIL_
print)
-44
Title Signature Gar crL
(over)
DOH-1555 (02/2004)