Gates, Theron NtVV YUKFK J I A I E ULF'AK I MEN I Oh HEALTH tl— l b
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Theron Floyd Gates Male
Date of Death Age If Veteran of U.S.Armed Forces,
November 18, 2013 66 War or Dates
Place of Death Hospital, Institution or
. City, Town or Village Street Address 40 Hartshorn Road
rF Manner of Death 1771 Natural Cause ❑ Accident 0 Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
11 Medical Certifier Name Title
Roberta Miller, M.D. Dr.
Address
16 Crimson Oak Court Schenectady, NY 12301
Death Certificate Filed District Number Register Number
City, Town or Village 95/ /7
❑Burial Date Cemetery or Crematory
November 20, 2013 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
�„ and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
s:' Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01077
Address
123 Main St., Argyle NY 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 c Address
rt Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued I i/2.4 i) Registrar of Vital Statistics UCtit_C Q-0 -
(signature)
District Number 51 SI Place C
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
, Date of Disposition 11/20/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) 4(lot number) (grave number)
Name of Sexton or Person in Charge of Premises A III. 3tiudig'
(pie!!se print)
- Signature ATitleClICitkrttreit
(over)
DOH-1555 (02/2004)