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Haymon, Gordon NEW YORK STATE DEPARTMENT OF HEALTH fi Pi Z Vital Records Section Burial - Transit Permit . Name First Middle Last Sex Gordon Haymon Male Date of Death Age If Veteran of U.S. Armed Forces, July 2, 2018 67 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death Natural Cause ❑ Accident ❑ Homicide ElSuicide ❑ Undetermined El❑ Pending 0 Circumstances Investigation W Medical Certifier Name Title Timothy Murphy, Address v 52 Haviland Ave Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls f -5. ,Q I `3e Li 0 Burial Date Cemetery or Crematory July 3, 2018 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbi.ry,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address Hold 41 Date Point of ❑Transportation Shipment by Common Destination a Carrier ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078 Address 136 Main Street, South Glens Falls NY 12803 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address w Permission is her by ranted to dispose of the huma remains •escribed ove as indi•ated. Date Issued O Registrar of Vital S tistics /j �� . <! �-- (signature) District Number 0 / Place L��r- 4 17 J kV I certify that the remains of the decedent identified above were disposed of in accordan with this permit on: Date of Disposition 07/03/2018 Place of Disposition Quaker Road Queensbury,N 12804 W (address) _ (section) ,(lot number) (grave number) Name of Sexton or Pers• on i6n Charge of Premises f(r. N 2 V (please print) W Signature Title f aftivill'L (over) DOH-1555 (02/2004)