Stetson, Gordon NEW YORK STATE DEPARTMENT OF HEALTH # S'II
Vital Records Section '` - ! Burial - Transit Permit
Name First Middle Last Sex
Gordon LaRoy Stetson Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/12/2012 81 War or Dates Korea
l Placed€-Leath �� ��„S-2 G_ Hospital, Institution or 77 f f.5z'6e% /
inCit<T oW r Village �i■ a Street Address Deceased's Residence %'d -i9f,re- .-0
ill
Manner of Death Natural Cause ❑ Accident 0 Homicide 0 Suicide ❑ Undetermined ❑ Pending
o Circumstances Investigation
W Medical Certifier Nam e ,,r)
Ci /�, !Gig/ /P- CY//t/,< tle �®14,02e�,
prss
of7acar-i,/,,,, ‘/J) (PlAr7(er-1 e:e- /2 -. ?
Death Certificate Filed District Number r L 6'Z Register Number 1
City, Town or Village
0 Burial Date or Crematory, w/ Pflc - y10/17/2012 U y --,,,
❑Entombment Address /7)/ ,%
®Cremation (A l/Ce f "--j //!, �f1 //<< �7/ o V
Date Place Removed
a ❑ Removal and/or Held
and/or Address
p Hold
CO Date Point of
fib. ❑Transportation Shipment
CO by Common Destination
a. Carrier
Date Cemetery Address
❑Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above _
Address
X
LU
Permission is her by ranted to dispose of the human re ai de ribed e as 9 dicate•. , •
Date Issued /0 /.5 /a Registrar of Vital Statistics * 7 / _
(signature) 1
District Number ‘../-6..J�g Place___J (4.-d
I certify that the remains of the decedent identified above were disposed oft in accordance with this permit on:
w Date of Disposition ►0-iq-11— Place of Dispositionvuv �. r►i.�
(address)
it (section) (lot number) (grave number)
CI Name of Sexton or Person in Charge f Premises �flS� �-
W (plese print)
Signature Title CQ1MPr D2
(over)
DOH-1555(02/2004)