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Jones, Gordon if2c NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middl- Last Sex Gordon Waller Jones Male Date of Death Age If Veteran of U.S.Armed Forces, 01/05/2018 88 Years War or Dates 1951-1952 Place of Death Hospital, Institution or City, Town or Village Queensbury Town Street Address The Stanton Nursing And Rehabilitation Centre Manner of Death©Natural Cause El Accident El Homicide El Suicide r7 Undetermined ID Pending Circumstances Investigation Medical Certifier Name Title Suzanne Blood MD Address 152 Sherman Ave,Queensbury Town,New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Queensbury 5657 5 El Burial Date Cemetery or Crematory 01/08/2018 Pine View Crematory ❑Entombment Address ®Cremation Queensbury Town, New York Date Place Removed _ El Removal and/or Field and/or Address Hold Date Point of r f Q Transportation Shipment by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077 •. Address 123 Main St,Argyle,New York 12809 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/08/2018 Registrar of Vital Statistics Caroline 7fBar6er(c(ectronicallySigned) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: p ;x Date of Disposition 1/9 if Place of Disposition - 1410--� (�►*t,ib✓ A; (address) (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premi s 1�' `'^`r y �1 (Plse print) Signature G � Title f h of (over) DOH-1555(02/2004)