Gillingham, Gary NEW YORK STATE DEPARTMENT OF HEALTH
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Vital Records Section Burial - Transit Permit
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Name First Middle Last Sex
Gary Raymond Gillingham Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 21, 2013 57 War or Dates
I• Place of Death Hospital, Institution or
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W ty, Town or Village Glens Falls Street Address Glens Falls Hospital
WI Manner of Death jj Natural Cause ❑ Accident ❑ Homicide ❑ Suicide 0 Undetermined ri Pending
Circumstances Investigation
W" Medical Certifier Name Title
C Ageel A. Gillani, M.D. Dr.
Address
102 Park St Glens Falls, NY 12801
Death Certificate Filed District Number Registerijber
City, Town or Village 5601
❑Burial Date Cemetery or Crematory
August 26, 2013 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
a and/or Address
F. Hold
(0 Date Point of
a. ❑ Transportation Shipment
tl! by Common Destination
f Carrier
11 Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I—•' Remains are Shipped, If Other than Above
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2 Address
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CIL' Permission is hereby granted to dispose of the human remains de r'be a e Gated.
Date Issued 08 G/..1Ql3 Registrar of Vital Statistics
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District Number 5601 Place �fjSt /./ , 4A/ /c2 5��/
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w• Date of Disposition g,28-/3 Place of Disposition f/ v f,G/ Olee4e..,r;44/1-7"
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re (section) /C1 �/,- � (lot number) (grave number)
O Name of Sexton s Charge of Premises CJ7 �� ��
C����n� (please print)
ill Signatur Title
(over)
DOH-1555 (02/2004)