Gray, Gary 2 7
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gary A. Gray Male
Date of Death Age If Veteran of U.S.Armed Forces,
July 1,2005 56 War or Dates
Place of Death Hospital, Institution or
Z City,Town or Village City of Glens Falls Street Address Glens Falls Hospital
LLI G Manner of Death 0 Natural Cause ❑ Accident El Homicide El Suicide El Undetermined El Pending
Circumstances Investigation
IU
0 Medical Certifier Name Title
W G Timothy E.Murphy Coroner
Address
52 Haveland Ave.,Glens Falls,NY 12801-
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 3 9'
❑ Burial Date Cemetery or Crematory
7/5/2005 Pine View Crematory
❑ Entombment Address
0 Cremation Queensbury,NY
Date Place Removed
ZO El Removal and/or Held
and/or Address
p Hold
N Date Point of
d ❑ Transportation Shipment
(4 by Common Destination
G Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00034
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
F, Remains are Shipped, If Other than Above
- Address
LC
cu
a. Permission is hereby granted to dispose of the human re ins d cribed abor...,�as indi ted.
Date Issued 7-5-05 Registrar of Vital Statistics a_.Q��,� G __-
gnature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in'ac)cordance with this permit on:
F— P N. �''JJ'K( ('b ) teR) l�
`Z Date of Disposition �� 6-Q 5' Place of Disposition / r U�
I (address)
W
cn (se ion) (lot number) number)
LK
OG tip Name of Sexton or Person in Charge of Premises -U(
Z (please print) `W Signature66 Title �, ? k 1Z
DOH-1555(02/2004) (over)