Grant, Jr. Gary fs7Z.
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gary Wayne Grant Jr Male
iMi Date of Death Age If Veteran of U.S. Armed Forces,
07/08/2018 41 years War or Dates No
} Place of Death Hospital, Institution or
City,max q Schenectady Street Address Ellis
• Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined ri Pending
W. Circumstances Investigation
tilij Medical Certifier Name Title
G Renee Argubano M D
Address
Pi 11 Tallow Wood Dr, Clifton Park, N Y 12065
Death Certificate Filed District Number Register Number
Diii City,XX QX cXXXX a Schenectady 4601 611
tEl Burial Date Cemetery or Crematory
❑ 07/16/2018 Pine View Crematorium
tombment Address
Cremation Quaker Rd, Queensbury, N Y
Date Place Removed
Kri Removal and/or Held
and/or Address
Hold
Date Point of
.0`0 Transportation Shipment
as by Common Destination
iiiil Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home 01079
ift Address
82 Broadway, Ft Edward, N Y 12828
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
cr.
its
',.7: Permission is hereby granted to dispose of the human remain d scribed a ve a - dicated.
iE Date Issued 07/11/2018 Registrar of Vital Statistics �(,(J�,�
(signature)
District Number4601 Place Schenectady
nii I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k ILI Date of Disposition 1 11 Ali Place of Disposition 1 D
Y ,rr A--
f
(address)
ili
c (section) (lot umber) (grave number)
0
• Name of Sexton or Person in Charge of Premises 441.- ,_c Ili
(please print)
III A
SignatureA Title l'i'+ ,1Zvt-
(over)
DOH-1555 (02/2004)